Green tea leaves extract with low concentration of EGCG can provide health benefits without causing renal damage

Green tea or its concentrated extract is coveted for its health promoting catechin-like polyphenols, especially epigallocatechin-3-gallate (EGCG). However, its amicable efficacy is now being doubted considering the recent occurrence of several cases of hepato- and nephrotoxicity, after the ingestion of EGCG-fortified (≥85–90%) nutritional supplements. Therefore, the current study was carried out to ascertain the effect of green tea leaves extract (GTE), having low EGCG content (73.8%), on liver and kidney functions of male Wistar rats using various in vivo experiments and in vitro radical scavenging activity. In terms of acute toxicity, GTE was observed to be safe when delivered at a dosage of 2000 mg kg−1 body weight (BW). Oral delivery of GTE for 28 days at a concentration of 200 mg kg−1 BW/day did not trigger sub-acute toxicity to the liver and kidneys, as per serum biochemical analyses and histopathological examination. In contrast, GTE counteracted the effects of carbon tetrachloride (a potent hepato-degenerative compound) on the liver. Furthermore, increase in high-density lipoprotein―cholesterol with concomitant lowering of serum triglycerides and low-density lipoprotein―cholesterol were noticed in GTE-treated rats. These findings suggest that low EGCG containing GTE, with appreciable antioxidant activity (IC50 = 53.18–71.28 μg mL−1), can serve as a hepatoprotective, hypolipidemic, and hypocholesterolemic ingredient.

Transcutaneous Partial Pressure of Oxygen Measurement in Advanced Chronic Venous Insufficiency as a Marker of Tissue Oxygenation

Purpose

Determination of oxygen concentration in tissues affected by chronic venous insufficiency (CVI) has shown inconsistent results over the years and has confounded the pathophysiology of venous diseases. This study measured transcutaneous partial oxygen pressure (TcPO₂) levels in patients with CVI to assess oxygenation and variation in oxygenation according to CVI stage.

Methods

Materials and A prospective study was performed on consecutive patients with unilateral CVI. TcPO₂ of diseased and unaffected limbs was measured in the supine and dependent positions. A single TcPO₂ value was measured at the site of greatest skin change or at the edge of the ulcer. The TcPO₂ values were analyzed and compared according to stage.

Results

A total of 96 patients were included in the study with C4 (24.0%), C5 (19.8%), and C6 (56.3%) disease. The mean age was 44.7 years, and 85 (88.5%) were male. There was a statistically significant (P<0.01) difference in mean TcPO₂ levels between the unaffected limb (supine, 32.1 mmHg; dependent, 50.7 mmHg), C5 diseased limb (supine, 16.6 mmHg; dependent, 35.5 mmHg), and C6 diseased limb (supine, 24.2 mmHg; dependent, 40.4 mmHg). In the supine and dependent positions, the mean TcPO₂ in the affected limb was significantly lower (P<0.01) than that in the unaffected limb.

Conclusion

TcPO₂ in advanced CVI can be used as a marker of oxygenation status. This is the first study in an Indian population looking at the relevance of TcPO₂ in the prognostication of advanced CVI.

Balanced Steady-State Free Precision and Time of Flight Noncontrast Magnetic Resonance Angiography in Peripheral Arterial Disease

Purpose To determine the diagnostic efficacy of balanced steady-state free precession (bSSFP) and time-of-flight (TOF)-based noncontrast magnetic resonance angiography (NC-MRA) in lower limb peripheral arterial disease (PAD).

Material and Methods 10 patients with suspected PAD underwent both NC-MRA (bSSFP and 2D TOF) and contrast-enhanced MR angiography (CE-MRA)/CT angiography (CTA). A total of 170 arterial segments (17 segments in each patient) were analyzed on NC-MRA and compared with CE-MRA/CTA for quality of images and for estimating the degree of stenoses. Image quality was graded as 1—poor, 2—fair, 3—good, and 4—excellent. The degree of stenoses was graded as 0—normal, 1— ≤ 50% narrowing, 2— > 50% narrowing, 3—near complete/100% occlusion. Sensitivity, specificity, positive predictive value, and negative predictive value of NC-MRA in identifying significant stenosis, as compared with CE-MRA/CTA, were estimated.

Results a) Mean grade of the image quality of NC-MRA was 3.10 and the CE-MRA/CTA was 3.64. b) The agreement in the estimation of the degree of stenosis on NC-MRA as compared with CE-MRA/CTA was substantial in aortoiliac segments (weighted kappa 0.646 [95% CI] [0.361–0.931] [p < 0.001]), almost perfect in femoropopliteal segments (weighted kappa 0.911 [95% CI] [0.79–1.032] [p < 0.001]), and poor in infrapopliteal segments (weighted kappa 0.052 [95% CI] [0.189–0.293] [p < 0.33587]).

Conclusion TOF and bSSFP-based NC-MRA was found to be comparable to the CE-MRA/CTA in the evaluation of PAD in lower limbs in the aortoiliac and femoropopliteal regions. NC-MRA was especially helpful in assessing the aortoiliac vessels and femoropopliteal vessels, with the imaging of infrapopliteal arteries being suboptimal.

Acid and heat fastness in microsporidia: How acid fast are acid fast microsporidium?

Microsporidia are obligate spore-forming microorganisms with strong resemblance to fungi and can affect almost every organ system in immunocompetent or immunocompromised individuals. Mixed infections are also reported in immunocompromised hosts. Microsporidial spores show marked morphological variations and the small and slender forms can resemble bacilli. Modified Zeihl Neelsen (ZN) stain, cold method demonstrates them as bright red in color, leaving several spores blue or incompletely stained; thus, they are reported as weakly or variably acid fast. Variability in staining results with ZN stain and considering the fact that Mycobacterium tuberculosis, the commoner bug in developing countries is identified by its resistance to stronger acids on ZN staining, authors wished to demonstrate acid and heat fastness in microsporidium using corneal tissue specimens. Microsporidial spores stained bright red in color with conventional ZN stain, demonstrated strong acid fastness, and interestingly the staining results improved on heating. Thus, the authors conclude that they are strongly acid and heat fast and care must be warranted so that they are not misdiagnosed as Mycobacterium or other acid-fast organisms. Careful observation of morphology, battery of special stains, and molecular diagnostics should be advocated for diagnostic confirmation. To the best of the authors' knowledge, this is the first explicit report on acid and heat fastness on microsporidial spores.

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

BACKGROUND

The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME).

METHODS

This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up.

RESULTS

There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality.

CONCLUSIONS

SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.

Rapid build-up of high-throughput screening microarrays with biochemistry gradients via light-induced thiol-ene "click" chemistry

Microarrays have become extremely powerful experimental tools for high-throughput screening of cell behaviors in multivariate microenvironments. Herein, a microarray-based high-throughput platform with biochemistry gradients was developed using poly(limonene carbonate) (PLimC) as a substrate through thiol-ene click chemistry. ATR-IR, XPS, Raman spectrum, and water contact angle results demonstrated that the sulfhydryl molecules, including PEG (polyethylene glycol) and RGD (arginine-glycine-aspartic acid) peptide, could be grafted onto PLimC substrates, while the grafting density could be well controlled by regulating the intensity of UV irradiation. Then, microarrays with a gradient of RGD grafting density were fabricated by using UV irradiation patterned by a photomask and a gradient light filter. Adhesion experiments of smooth muscle cells and 3T3-L1 mouse embryonic fibroblast cells proved that the cell behaviors were highly determined by the RGD density. This platform puts forward a facile, high-throughput method to study the effect of biochemical signal density on cell behaviors.

Systematic Review of Erythropoietin (EPO) for Neuroprotection in Human Studies

Erythropoietin (EPO) is an exciting neurotherapeutic option. Despite its potential, concerns exist regarding the potential for thrombosis and adverse events with EPO administration in normonemic adults. Systematic review of literature using PRISMA guidelines to examine the application and risks of EPO as a treatment option for neuroprotection in normonemic adults. Independent, systematic searches were performed in July 2019. PubMed (1960-2019) and the Cochrane Controlled Trials Register (1960-2019) were screened. Search terms included erythropoietin, neuroprotection, and humans. The PubMed search resulted in the following search strategy: ("erythropoietin" [MeSH Terms] OR "erythropoietin" [All Fields] OR "epoetin alfa" [MeSH Terms] OR ("epoetin" [All Fields] AND "alfa" [All Fields]) OR "epoetin alfa" [All Fields]) AND ("neuroprotection" [MeSH Terms] OR "neuroprotection" [All Fields]) AND "humans" [MeSH Terms]. PubMed, Cochrane Controlled Trials Register, and articles based on prior searches yielded 388 citations. 50 studies were included, comprising of 4351 patients. There were 13 studies that noted adverse effects from EPO. Three attributed serious adverse effects to EPO and complications were statistically significant. Two of these studies related the adverse events to the co-administration of EPO with tPA. Minor adverse effects associated with the EPO group included nausea, pyrexia, headache, generalized weakness and superficial phlebitis. Most published studies focus on spinal cord injury, peri-surgical outcomes and central effects of EPO. We found no studies to date evaluating the role of EPO in post-operative pain. Future trials could evaluate this application in persistent post-surgical pain and in the peri-operative period.

Use of insulin glargine during pregnancy: A review

BACKGOUND AND AIMS

Hyperglycemia during pregnancy is increasing globally. Insulin therapy is considered the standard of care for its optimum management. Insulin glargine, in spite of widespread use in non-pregnant adults, lacks randomized controlled trial evidence as safe basal insulin during pregnancy. Aim of this review is to discuss major available evidences and recommendations on the use of insulin glargine during pregnancy.

METHODS

Evidences related to use of insulin glargine during pregnancy, including animal studies, placental transfer studies, case reports as well as observational studies were retrieved using PUBMED & Google scholar. Recommendations regarding use of insulin glargine during pregnancy by international and Indian organizations were reviewed.

RESULTS

Trans-placental transfer studies show that insulin glargine does not cross placenta when used at therapeutic concentrations. Although there are no randomized controlled trials on insulin glargine in pregnancy, it's use during pregnancy is not associated with any adverse maternal or neonatal outcomes as shown in many case reports and observational studies (both prospective and retrospective). It's use during pregnancy is hence considered safe by many organizations across the globe.

CONCLUSIONS

Insulin glargine can be continued safely during pregnancy in women who are already taking it prior to pregnancy and have achieved good glycemic control with it. However we require preferably randomized controlled trials or large prospective observational studies to establish it as first line or preferred basal insulin for management of hyperglycemia during pregnancy.

Serial Imaging of Virus-Associated Necrotizing Disseminated Acute Leukoencephalopathy (VANDAL) in COVID-19

BACKGROUND AND PURPOSE

Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up.

MATERIALS AND METHODS

We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy.

RESULTS

All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%).

CONCLUSIONS

Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.

Role of magnetic resonance imaging in breast cancer management

Magnetic resonance imaging (MRI) of the breast is primarily used as a supplemental tool to breast screening with mammography or ultrasound. A breast MRI is mainly used for women who have been diagnosed with breast cancer, to help measure the size of the cancer, look for other tumors in the breast, and to check for tumors in the opposite breast. For certain women at high risk for breast cancer, a screening MRI is recommended along with a yearly mammogram. MRI is known to give some false positive results which mean more test and/or biopsies for the patient. Thus, although breast MRI is useful for women at high risk, it is rarely recommended as a screening test for women at average risk of breast cancer. Also, breast MRI does not show calcium deposits, known as micro-calcifications which can be a sign of breast cancer.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial)

There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg^-1 based on factor IX) or fresh frozen plasma (15 ml.kg^-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α₂ -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.

Patterns of arterial involvement and feasibility of revascularization in thromboangiitis obliterans: a tertiary care centre experience

BACKGROUND

Arterial revascularization is seldom considered as a treatment option in thromboangiitis obliterans (TAO) due to diffuse segmental involvement of medium- and small-sized extremity vessels. Although typical angiographic features include bilaterally symmetrical involvement of infrapopliteal vessels, larger vessels too can be affected. Similarly, there could be distal target vessels feasible for revascularization. This study was conducted to describe the patterns of arterial involvement in TAO and assess the feasibility of revascularization.

METHODS

The study was approved by the Institutional Review Board and research ethics committee of Christian Medical College, Vellore (IRB no: 12034). A retrospective study was conducted in the Department of Vascular Surgery, Christian Medical College, Vellore, India, between January 2009 and December 2018. There were 329 patients who fulfilled the clinical criteria for TAO of whom 83 had an angiogram done. These 83 patients formed the study cohort.

RESULTS

Large vessel involvement was seen in 56.6% of patients and 79.5% of patients had at least one or more distal target artery feasible for revascularization. The anterior tibial artery and peroneal artery were the most common target vessels that were patent for revascularization. Of the 22 patients who underwent revascularization (16 bypasses and six angioplasties), the patency rate was 64.8% and the limb salvage rate was 80.9% at the end of 6 months.

CONCLUSION

The study shows that one-third of our patients with TAO have a distal target artery feasible for revascularization. As most of the affected patients are in the economically productive age group, every attempt should be made to salvage the limb with revascularization for which the use of angiography should be more liberal.

Anaemia in cardiac surgery - a retrospective review of a centre's experience with a pre-operative intravenous iron clinic

Pre-operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri-operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. We established a pre-operative anaemia clinic to aid identification and treatment of patients with iron deficiency anaemia scheduled for elective cardiac surgery. We present a retrospective observational review of our experience from January 2017 to December 2019. One-hundred and ninety patients received treatment with intravenous iron, a median of 21 days before cardiac surgery. Of these, 179 had a formal laboratory haemoglobin level measured before surgery, demonstrating a median rise in haemoglobin of 8.0 g.l^-1 . Patients treated with i.v. iron demonstrated a significantly higher incidence of transfusion (60%) compared with the non-anaemic cohort (22%) during the same time period, p < 0.001. Significantly higher rates of new requirement for renal replacement therapy (6.7% vs. 0.6%, p < 0.001) and of stroke (3.7% vs. 1.2%, p = 0.010) were also seen in this group compared with those without anaemia, although there was no significant difference in in-hospital mortality (1.6% vs. 0.8%, p = 0.230). In patients where the presenting haemoglobin was less than 130 g.l^-1 , but there was no intervention or treatment, there was no difference in rates of transfusion or of complications compared with the anaemic group treated with iron. In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non-anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri-operative risk to non-anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real-world setting.

Morphology of Proximal Femur in South-West Coast of India

Introduction

With a higher proportion of young individuals undergoing uncemented hip arthroplasty, a close match in the dimension of the proximal femur and the implanted prosthesis is paramount. This is a study to gain insight into geographical variation in proximal femur morphology to determine the reference values to design uncemented femoral stems for a south Indian population, and also the effect of ageing and gender on the proximal femur morphology.

Materials and Methods

The study comprised of two groups. For the first group, 50 unpaired dry femur bones were obtained from adult human cadavers; and the second group was a clinical group of 50 adult patients. Standardised radiographic techniques were used to measure the extra-cortical and intra-cortical morphometric parameters. Based on these, dimensionless ratios were calculated to express the shape of the proximal femur. The data were expressed in terms of mean and standard deviation and a comparison made with other studies.

Results

A significant difference was noted across various population subsets within the Indian subcontinent and also in comparison to the Western population, suggestive of regional variation. The measurements made in cadaveric bone differed significantly from those in live patients, especially the femoral head diameter and extra-cortical and intra-cortical width. Femoral offset, head height and diameter were significantly less in females.

Conclusion

The south Indian population needs customised implants with an increase in neck shaft angle and a decrease in intra-cortical and extra-cortical width for press fit in hip arthroplasty. The variation between the two sexes must also be accounted for during prosthesis design.