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.

Antenatal diagnosis of large sacro-coccygeal teratoma with foetal cardiomegaly and hydrops

We report the case of a young primigravida who presented with a 20 weeks pregnancy with a previous diagnosis of uterine fibroid. However, ultrasound evaluation revealed the presence of a large sacro-coccygeal teratoma in the foetus which was heterogeneous with cystic areas and calcific foci, and showed increased vascularity. There was also evidence of foetal cardiomegaly and hydrops foetalis, indicated by subcutaneous oedema in the foetus,thickened placenta and polyhydramnios. The presence of hydrops with sacro-coccygeal teratoma has a grave prognosis for the mother and child; hence termination of pregnancy was done. A 20 weeks old foetus with a huge sacro-coccygeal mass, which was ruptured at many places and showed areas of active bleed, was expelled.

Novel method of using dynamic electrical impedance signals for noninvasive diagnosis of knee osteoarthritis

Osteoarthritis (OA) of knee is the most commonly occurring non-fatal irreversible disease, mainly in the elderly population and particularly in female. Various invasive and non-invasive methods are reported for the diagnosis of this articular cartilage pathology. Well known techniques such as X-ray, computed tomography, magnetic resonance imaging, arthroscopy and arthrography are having their disadvantages, and diagnosis of OA in early stages with simple effective noninvasive method is still a biomedical engineering problem. Analyzing knee joint noninvasive signals around knee might give simple solution for diagnosis of knee OA. We used electrical impedance data from knees to compare normal and osteoarthritic subjects during the most common dynamic conditions of the knee, i.e. walking and knee swing. It was found that there is substantial difference in the properties of the walking cycle (WC) and knee swing cycle (KS) signals. In experiments on 90 pathological (combined for KS and WC signals) and 72 normal signals (combined), suitable features were drawn. Then signals were used to classify as normal or pathological. Artificial multilayer feed forward neural network was trained using back propagation algorithm for the classification. On a training data set of 54 signals for KS signals, the classification efficiency for a test set of 54 was 70.37% and 85.19% with and without normalization respectively wrt base impedance. Similarly, the training set of 27 WC signals and test set of 27 signals resulted in 77.78% and 66.67% classification efficiency. The results indicate that dynamic electrical impedance signals have potential to be used as a novel method for noninvasive diagnosis of knee OA.

Structure and content of the Entamoeba histolytica genome

The intestinal parasite Entamoeba histolytica is one of the first protists for which a draft genome sequence has been published. Although the genome is still incomplete, it is unlikely that many genes are missing from the list of those already identified. In this chapter we summarise the features of the genome as they are currently understood and provide previously unpublished analyses of many of the genes.

Human C-reactive protein promotes oxidized low density lipoprotein uptake and matrix metalloproteinase-9 release in Wistar rats

C-reactive protein (CRP) is present in the atherosclerotic plaques and appears to promote atherogenesis. Intraplaque CRP colocalizes with oxidized low density lipoprotein (OxLDL) and macrophages in human atherosclerotic lesions. Matrix metalloproteinase-9 (MMP-9) has been implicated in plaque rupture. CRP promotes OxLDL uptake and MMP induction in vitro; however, these have not been investigated in vivo. We examined the effect of CRP on OxLDL uptake and MMP-9 production in vivo in Wistar rats. CRP significantly increased OxLDL uptake in the peritoneal and sterile pouch macrophages compared with human serum albumin (huSA). CRP also significantly increased intracellular cholesteryl ester accumulation compared with huSA. The increased uptake of OxLDL by CRP was inhibited by pretreatment with antibodies to CD32, CD64, CD36, and fucoidin, suggesting uptake by both scavenger receptors and Fc-gamma receptors. Furthermore, CRP treatment increased MMP-9 activity in macrophages compared with huSA, which was abrogated by inhibitors to p38 mitogen-activated protein kinase, extracellular signal-regulated kinase (ERK), and nuclear factor (NF)-kappaB but not Jun N-terminal kinase (JNK) before human CRP treatment. Because OxLDL uptake by macrophages contributes to foam cell formation and MMP release contributes to plaque instability, this study provides novel in vivo evidence for the role of CRP in atherosclerosis.

Comparison of the incidence and severity of cough induced by sufentanil and fentanyl: a prospective, randomised, double-blind study

We compared the incidence and severity of cough following a bolus of sufentanil with that following fentanyl in 510 patients, randomly allocated to receive sufentanil 0.3 microg.kg(-1), fentanyl 3 microg.kg(-1) or 5 ml sterile water intravenously over 5 s. Coughing was graded depending on the number of coughs as mild (1-2), moderate (3-5) and severe (> 5). The incidence of coughing was higher after sufentanil (26/165; 15%) and fentanyl (54/169; 32%) than in the control group (0/168; p < 0.001). Sufentanil was also associated with a lesser severity (p = 0.039) of coughing compared with fentanyl. We conclude that equipotent boluses of sufentanil and fentanyl increase the incidence of cough, although the incidence and severity of coughing with sufentanil are less than those with fentanyl.

Electrical impedance signal analysis in assessing the possibility of non-invasive diagnosis of knee osteoarthritis

Knee osteoarthritis (OA) is a degenerating disorder that leads to pain, disability and dependence. Although significant numbers of elderly people are affected by this irreversible damage, not many non-invasive methods have been found that can detect onset of OA. The traditional x-ray has the disadvantage of detecting a problem only after many changes have taken place. Others, such as MRI and ultrasound, are either expensive or unsuitable for mass screening and repeated use. In this paper, an attempt has been made to study the usefulness of electrical impedance plethysmography (EIP) in non-invasive diagnosis of knee OA. In two experiments on 10 OA knees and eight control knees in groups aged 45 - 65 years (OA group: 62.40 +/- 3.47 years, controls: 53.38 +/- 8.55 years), knee swing (active flexion and extension of leg in sitting position, KS) and normal walking (WN) electrical impedance changes (DeltaZ) around the knee were analysed. The results indicate that there is significant difference in amplitudes of signals. Difference in mean of variances of two groups was significant (p < 0.05) for KS and WN. The difference in the mean rms values was also significant (p < 0.05) for KS and WN. Impedance changes suggest that EIP signal around the knee have the potential for non-invasive diagnosis of knee OA.

Evaluation of gemcitabine versus cisplatinum as an adjunct to radiotherapy in locally advanced carcinoma uterine cervix

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Background: Locally advanced carcinoma cervix patients are treated by a combination of external beam radiation and brachytherapy. Concurrent chemo-radiotherapy has been an active area of investigation in such patients. In this present study, we have compared two chemotherapy drugs- cisplatinum vs gemcitabine along with radiotherapy in loco-regionally advanced carcinoma cervix with the purpose of evaluating loco-regional disease control and tolerability of these combinations. Methods: This study was undertaken on 65 biopsy-proven patients with stage IIb- IIIb carcinoma cervix. All patients were treated with 50 Gy of external beam radiation with 2 Gy per fraction, 5 days a week followed by intra-cavitary radiotherapy (ICRT). Dose of ICRT delivered by high dose rate brachytherapy was 18 Gy by either of the two schedules, viz. 3 fractions of 6 Gy at weekly interval or 2 fractions of 9 Gy each at one week apart. The concurrent chemotherapy was either inj. Cisplatinum 35 mg/m2 IVI weekly (control group), or inj. gemcitabine 150 mg/m2 IVI weekly (Study group). Results: A total of 65 age and stage matched patients were recruited in the two arms of the study. We analyzed sixty patients who completed the above treatment protocol with 32 patients in control group and 28 in study group. Eighty-nine percent patients in study group had complete response (CR) to the above combination treatment vs. 72% CR in control arm (p< 0.05). However, overall response rate (CR+ PR) was similar in both the groups (96% in study group vs. 100% in control group). No patient in both the groups had grade IV skin reaction with only one patient in study group developing grade III skin toxicity. Grade III gastrointestinal (GI) toxicity was higher in study group as compared to controls (14% vs. 3%) with none of the patients experiencing grade IV GI toxicity. No other significant toxicity was encountered in this study. Conclusions: We can conclude that synchronous chemo-radiotherapy using either gemcitabine or cisplatinum as radiation sensitizer is feasible in locally advanced carcinoma cervix with similar overall response rate and acute toxicity profile with a significantly higher complete response rate when gemcitabine is used as a chemotherapeutic drug.

No significant financial relationships to disclose.

Vitamin E: inflammation and atherosclerosis

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the western world with its incidence increasing lately in developing countries. Several lines of evidence support a role for inflammation in atherogenesis. Hence, dietary micronutrients having antiinflammatory properties may have a potential beneficial effect with regard to CVD. Vitamin E is a potent antioxidant with antiinflammatory properties. It comprises eight different isoforms: four tocopherols (T) (alpha, beta, gamma, and delta) and four tocotrienols (T3) (alpha, beta, gamma, and delta). A wealth of data is available for the preventive efficacy of alpha-T. alpha-T supplementation in human subjects and animal models has been shown to be antioxidant and antiinflammatory in terms of decreasing C-reactive protein (CRP) and release of proinflammatory cytokines, the chemokine IL-8 and PAI-1 levels especially at high doses. gamma-T is effective in decreasing reactive nitrogen species and also appears to have antiinflammatory properties; however, there are scanty data examining pure gamma-T preparations. Furthermore, tocotrienols (alpha and gamma) also have implications for prevention of CVD; however, there are conflicting and insufficient data in the literature with regards to their potency. In this chapter, we have gathered recent emerging data on alpha-T specifically and also have given a composite view of gamma-T and tocotrienols especially with regards to their effect on inflammation as it relates to CVD.

Expression and Functional Analysis of Fibulin-1 (Fbln1) During Normal and Abnormal Placental Development of the Mouse

The extracellular matrix protein fibulin-1 (FBLN1) is an important component of blood vessel walls, as shown by the lethality of mice with homozygous targeted deletion of the Fbln1 gene. Here, we show that a murine placental overgrowth phenotype is associated with elevated Fbln1 transcript levels, suggesting that the gene and its product have a functional role in placentation. Fbln1 exhibits a specific expression pattern in the mouse placenta. Transcripts could not be detected prior to day 12. In subsequent stages, Fbln1 was expressed strongly in the spongiotrophoblast. Other sites of expression were endothelia of large fetal blood vessels, a tissue type reported to not express this gene. In addition, a subset of giant cells expressed the gene. This giant cell specific expression was strongly increased in hyperplastic placentas. Analysis of the placentation in fibulin null mice did not show any abnormality. Attempts to rescue the placental phenotypes of a congenic model of interspecies hybrid placental dysplasia (IHPD) by normalizing expression of Fbln1 proved that Fbln1 alone is not the key cause of phenotypes in these models of placental hyperplasia.

Expression and function of the gene encoding the voltage-dependent calcium channel beta3-subunit in the mouse placenta

Voltage-dependent Ca(2+) channels (VDCC) exist in most excitable cells and their properly regulated activity is essential for critical biological processes as many of these are sensitive to cellular Ca(2+) ion concentration. The ancillary cytoplasmic Ca(2+) channel beta subunits (CACNB) modulate Ca(2+) channel function and are required to enhance the number of functional channels in the plasma membrane. There are four genes encoding CACNB subunits and the gene encoding CACNB3 is over expressed in hyperplastic placentas of mouse interspecies hybrids. To determine the role of CACNB3 in the mouse placenta, we performed an expression and function analysis. Our results show that Cacnb3 exhibits specific spatial and temporal expression in the mouse placenta. Deletion of Cacnb3 does not produce a strong placental phenotype, which may be due to expression of other CACNB subunit encoding genes; however, sporadic occurrence of a labyrinthine architecture phenotype, characterized by reduced density of fetal blood vessels and decrease in pericyte number, could be observed. Down-regulation of Cacnb3 expression did not rescue placental hyperplasia in a model of interspecies hybrid placentas, which indicates that up-regulation in the hyperplastic placentas is a downstream event.

Quality of life and gender role behavior in disorders of sexual differentiation in India

OBJECTIVE

Culture-specific tools to assess longterm psychosocial outcomes for patients with disorders of sexual differentiation are scant. We conducted a study to develop tools for evaluating gender role behavior and health related quality of life for Indian adolescent patients with intersex disorders. We also studied factors important to parents while deciding sex of rearing for their baby.

METHODS

A 29-item gender role behavior questionnaire and an 18-item health related quality-of-life questionnaire were administered to 82 healthy controls, 13 patients with intersex disorders and 18 patients with type 1 diabetes mellitus. Internal consistency was checked by Cronbach's alpha and test-retest reliability using intra-class correlation coefficient. Responses of 28 parents to a questionnaire on factors affecting the decision of sex of rearing were recorded on a 5-point Likert scale in order of importance.

RESULTS

Cronbach's alpha was 0.92 and 0.75, and intra-class correlation coefficient 0.76 and 0.75, for the gender role behavior and quality-of-life questionnaires respectively, indicating a high degree of internal consistency and stability. The mean composite scores for healthy girls on the gender role behavior questionnaire (82.5 +/- 8.7) differed significantly from that for healthy boys (53.2 +/- 7.1, p <0.001). Factors important to parents while making decisions for sex of rearing were appearance of the genitalia, medical advice, ability to bear children and economic independence.

CONCLUSIONS

We have created valid tools to study gender role behavior and quality of life in adolescent patients with intersex disorders in India. We have also identified in a quantitative way the factors of greatest importance to parents while deciding sex of rearing. These results have direct utility in the management of patients with intersex disorders in India and other similar cultures.

Evaluation of a diclofenac transdermal patch for the attenuation of venous cannulation pain: a prospective, randomised, double-blind, placebo-controlled study

Venous cannulation, although a minor procedure, is often painful. The present study was planned to evaluate the efficacy of a diclofenac transdermal patch placed over the venepuncture site in decreasing the pain of cannulation. Seventy-two adults undergoing elective surgery were included in this randomised, prospective, double-blind, placebo-controlled study. Patients were divided into three equal groups. The Control group had a placebo adhesive patch placed on the both the dorsum of hand and the buttock; the Diclofenac-Buttock group had a placebo patch placed on the dorsum of the hand and a diclofenac transdermal patch on the buttock; the Diclofenac-Hand group had a diclofenac transdermal patch placed on the dorsum of hand and a placebo patch on the buttock. The patches were applied 1 h before cannulation. An 18G cannula was used for all venous cannulations. Pain during cannulation was assessed on a non-graduated 10-cm visual analogue scale. Median [interquartile range] pain scores were 3.0 [2.0-4.0] in the Diclofenac-Hand group, 5.0 [4.3-7.8] in the Diclofenac-Buttock group and 6.5 [4.5-7.0] in the Control group, p < 0.05. The numbers needed to treat were six and two in the Diclofenac-Buttock and Diclofenac-Hand groups, respectively. The application of a diclofenac transdermal patch at the cannulation site appears to be effective in decreasing cannulation pain.

Prophylactic gabapentin for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study

BACKGROUND

Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients.

AIM

To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy.

SETTINGS AND DESIGN

Double-blind, randomized, placebo-controlled study.

MATERIALS AND METHODS

Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded.

STATISTICAL ANALYSIS

"Z test" was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean+/-SD) within 24 hrs was compared using student t test. P value < 0.05 was considered significant.

RESULTS

There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2+/-92.4 microg) as compared to placebo group (505.9+/-82.0 microg; P =0.01).

CONCLUSION

Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

Evaluation of capsaicin ointment at the Korean hand acupressure point K-D2 for prevention of postoperative nausea and vomiting

The K-D2 point is the Korean hand acupressure point in Koryo Hand Therapy for prevention of postoperative nausea and vomiting. We evaluated the efficacy of capsaicin ointment at the K-D2 point in 186 patients undergoing laparoscopic cholecystectomy in a randomised, prospective, double-blind and placebo-controlled study. Patients were randomised to have either placebo ointment or capsaicin ointment applied to the K-D2 point of both hands 1 h before surgery under standardised anaesthesia. The ointment was removed 8 h later. Postoperative nausea and vomiting was evaluated 6 and 24 h following surgery. The incidence of postoperative nausea and vomiting was lower in the capsaicin group, with an absolute risk reduction (ARR) of 21%, a relative risk reduction (RRR) of 50% and a number-needed-to-treat (NNT) of 5 at 0-6 h (p = 0.001), and an ARR of 11%, a RRR of 85% and a NNT of 9 at 6-24 h (p = 0.003). The need for rescue anti-emetic treatment was also lower at 0-6 h (3 (3%) vs 11 (12%); p = 0.04) and at 6-24 h (5 (5%) vs 0; p = 0.02).

Opioid sparing during endotracheal intubation using McCoy laryngoscope in neurosurgical patients: the comparison of haemodynamic changes with Macintosh blade in a randomized trial

BACKGROUND

There is conflicting data in literature to show that the McCoy laryngoscope is less stressful and opioids can actually be avoided during laryngoscopy and intubation with the use of this laryngoscope.

AIM

A comparison of hemodynamic changes with McCoy vs Macintosh laryngoscope..

SETTINGS AND DESIGN

180 ASA I and II neurosurgical patients undergoing elective surgery for space occupying lesions were recruited. The study was was prospective, randomized and blinded in the setting of neurosurgical perioperative services.

METHODS AND MATERIALS

The patients were divided into four groups (Gr.1 McCoy and fentanyl; Gr. 2 McCoy and no fentanyl; Gr. 3 Macintosh and fentanyl; Gr. 4 Macintosh and no fentanyl). In Gr. 2 and 4 equivalent volume of saline was given in place of fentanyl as placebo. Heart rate, systolic and diastolic blood pressure were measured after laryngoscopy, after intubation and subsequently every minute for the next five minutes. The incidence of cough due to fentanyl treatment was observed.

STATISTICAL ANALYSIS

Haemodynamic changes were compared between and within groups using oneway ANOVA and repeated measures ANOVA. All analysis included 95% CI at 5% significance. The Mann Whitney U test was used for comparing incidence of cough.

RESULTS

No difference was found between McCoy laryngoscopy when done with or without fentanyl pretreatment (HR p=0.848, sys BP p=0.229 and diastolic blood pressure p=0.981). Significant changes in haemodynamic parameters were seen between Macintosh and McCoy laryngoscopy without fentanyl pretreatment (p<0.001) whereas changes were blunted with fentanyl pretreatment in Macintosh laryngoscopy (p<0.05).

CONCLUSIONS

McCoy laryngoscope blade is less stressful and fentanyl pretreatment is not necessary to attenuate haemodynamic responses with its use in ASA I and II patients.

Acupressure for prevention of pre-operative anxiety: a prospective, randomised, placebo controlled study

Pre-operative anxiety is associated with many unwanted effects such as increased analgesic and anaesthetic requirement, postoperative pain and prolonged hospital stay. In the present study, we investigated the effects of acupressure on pre-operative anxiety and bispectral index (BIS) values. Seventy-six adults, ASA grade I and II, undergoing elective surgery, were randomly assigned to two equal groups. Group 1 (control) received acupressure at an inappropriate site and group 2 (acupressure) received acupressure at extra 1 point. The study was conducted during the pre-operative period and the duration of the study was 40 min (acupressure was applied for 10 min and thereafter patients were observed for another 30 min). Anxiety was recorded on a visual stress scale (VSS) at the start of the study and thereafter at 10 and 40 min. BIS was recorded at 0, 2, 5, 10, 12, 15, 30 and 40 min. The VSS decreased in both groups following pressure application for 10 min: median VSS (interquartile range) were 5 (1) vs. 8 (1) in the acupressure and 7 (0) vs. 8 (1) in the control groups (p < 0.001). Both pre-operative anxiety and BIS decreased significantly during acupressure application at extra 1 point (p < 0.001). Acupressure is effective in decreasing both pre-operative anxiety and BIS; however, these effects are not sustained 30 min following release of acupressure. Further studies are needed to elucidate the duration for which acupressure is effective.

Vitamin E, oxidative stress, and inflammation

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Western world. Its incidence has also been increasing lately in developing countries. Several lines of evidence support a role for oxidative stress and inflammation in atherogenesis. Oxidation of lipoproteins is a hallmark in atherosclerosis. Oxidized low-density lipoprotein induces inflammation as it induces adhesion and influx of monocytes and influences cytokine release by monocytes. A number of proinflammatory cytokines such as interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha (TNF-alpha) modulate monocyte adhesion to endothelium. C-reactive protein (CRP), a prototypic marker of inflammation, is a risk marker for CVD and it could contribute to atherosclerosis. Hence, dietary micronutrients having anti-inflammatory and antioxidant properties may have a potential beneficial effect with regard to cardiovascular disease. Vitamin E is a potent antioxidant with anti-inflammatory properties. Several lines of evidence suggest that among different forms of vitamin E, alpha-tocopherol (AT) has potential beneficial effects with regard to cardiovascular disease. AT supplementation in human subjects and animal models has been shown to decrease lipid peroxidation, superoxide (O2-) production by impairing the assembly of nicotinamide adenine dinucleotide phosphate (reduced form) oxidase as well as by decreasing the expression of scavenger receptors (SR-A and CD36), particularly important in the formation of foam cells. AT therapy, especially at high doses, has been shown to decrease the release of proinflammatory cytokines, the chemokine IL-8 and plasminogen activator inhibitor-1 (PAI-1) levels as well as decrease adhesion of monocytes to endothelium. In addition, AT has been shown to decrease CRP levels, in patients with CVD and in those with risk factors for CVD. The mechanisms that account for nonantioxidant effects of AT include the inhibition of protein kinase C, 5-lipoxygenase, tyrosine-kinase as well as cyclooxygenase-2. Based on its antioxidant and anti-inflammatory activities, AT (at the appropriate dose and form) could have beneficial effects on cardiovascular disease in a high-risk population.

Morgagni Stewart morel syndrome - Additional features

A case of Morgagni Stewart Morel syndrome with progressive depression in frontal bone, headache, transient monoparesis, obesity; imbalance, neuropsychiatric symptoms and recurrent disc prolapse with absent right radial pulse is discussed. This syndrome was first mentioned 235 years back, but till now exact pathology is not known. Balance assessment using dynamic posturography was done, which revealed abnormal vestibular function. To our knowledge this is the first case examined for Dynamic Posturography.

Predictors of survival end points in patients with cancer of the cervix on long-term follow-up: inferences and implications from an audit of patients treated with a specific radiotherapy protocol

AIMS

An audit of patients with cancer of the cervix treated with a specified protocol of external beam radiotherapy (EXRT) followed by intracavitary brachytherapy (ICBT) was carried out to determine the prognosticators for major survival end points.

MATERIALS AND METHODS

Patients treated between 1991 and 2003 with a uniform protocol of EXRT (50 Gy/25 fractions/5 weeks) followed by high-dose-rate ICBT (18 Gy/3 fractions/3 weeks) were selected from the database. Various clinical and treatment parameters were evaluated for extent of locoregional response at completion of EXRT, namely absence or presence of gross residual tumour (AGRT and PGRT, respectively) and survival end points. These included locoregional disease-free survival (LDFS), disease-free survival (DFS) and overall survival (OS).

RESULTS

Of the 157 evaluable patients, 145 (92%) belonged to FIGO stages II and III. Eighty-three (53%) at completion of EXRT had AGRT, which was influenced by age and gross tumour features. The estimated 10-year LDFS, DFS and OS were 38.6%, 33.1% and 38.5%, respectively. Factors significant on univariate analysis for these survival end points were EXRT duration, ICBT time, overall treatment time (OTT) and EXRT response. On multivariate analysis, AGRT to EXRT, an OTT of < or = 67 days, and patients older than 50 years were the significant favourable determinants for all the above survival end points.

CONCLUSION

The audit highlights that younger people, especially those with bulky tumours that determine response to EXRT, are poor prognosticators for survival end points. They could perhaps benefit from treatment intensification regimens using chemoradiotherapy, provided that OTT is not unduly prolonged.

Problems and uncertainties with multiple point A's during multiple high-dose-rate intracavitary brachytherapy in carcinoma of the cervix

AIMS

This study evaluates the consequences of point A as a dose prescription point during multiple high-dose-rate (HDR) intracavitary brachytherapy (ICBT) in cancer cervix.

MATERIALS AND METHODS

Fifty patients who had received teletherapy were randomised into two groups of 25 to receive three HDR ICBT fractions of 6 Gy each at point A with either a flexible Ralstron (Shimadzu Corporation, Japan) or rigid Rotterdam (Nucletron, Netherlands) applicator. The orthogonal radiographs of the 150 applications were evaluated for applicator geometry and point A co-ordinates.

RESULTS

Irrespective of the nature and rigidity of the applicators, its various components exhibited a highly significant variation during multiple fractionated HDR ICBT. The Cartesian co-ordinates of point A (left and right) for the applicator geometry also showed significant variation during multiple HDR ICBT procedures. This resulted in an average shift of 9.5 mm (SD= +/-4.4) and 11.1 mm (SD= +/-6.4) in right point A, 10.2 mm (SD= +/-4.5) and 10.8 mm (SD= +/-6.6) in left point A for Ralstron and Rotterdam applicator, respectively, during the three HDR ICBT. Consequently, doses to both right and left point A's showed significant variation during multiple ICBT application and were independent of the applicator type.

CONCLUSION

Applicator variation in the components and spatial position in the pelvis during multiple HDR ICBT results in multiple point A's irrespective of the nature of applicator, leading to uncertainty in the dose prescription. These uncertainties, which have a bearing on clinical end points, could be minimised by shifting from point-based dose prescription to image-based target localisation and treatment planning in ICBT.

Efficacy of extracorporeal shock wave lithotripsy for solitary lower calyceal stone: a statistical model

OBJECTIVE

To evaluate the effect of inferior calyceal radiographic anatomy, number of extracorporeal shock wave lithotripsy (ESWL) sessions and stone size on the successful clearance of solitary inferior calyceal calculi after ESWL.

PATIENTS AND METHODS

In a prospective study between January 2001 and November 2002, 66 renal units with a solitary inferior calyceal calculus of < or = 2 cm were treated with electrohydraulic ESWL. The infundibulopelvic angle (two definitions), infundibulovertebral angle, inferior calyceal infundibular diameter, infundibular length, cortical thickness over the lower pole, number of minor calyces and stone size were determined from intravenous urography before treatment. The number of ESWL sessions was also included in the analysis. Treatments which produced residual fragments not clearing within 3 months of satisfactory fragmentation were considered as failures. All patients in whom the treatment failed were treated successfully by percutaneous nephrolithotomy. The data were then analysed using two different statistical methods; first by intravariable differences using the test of proportion (Fisher's test) and then all the variables together using logistic regression.

RESULTS

At 3 months 78.8% of the renal units were clear of stone. All intravariable differences were statistically significant except stone size (<1 cm, 1-2 cm). In a multivariate analysis of all variables, only stone size was the most important predictor for successful stone clearance (P = 0.03).

CONCLUSIONS

ESWL is the initial treatment of choice in selected patients with inferior calyceal stones. The stone size appears to be the most important predictor for stone clearance.

A case of dextrocardia, radial ray malformation and renal anomaly

A 12-year-old boy is described with bilateral radial club hands, scoliosis, hypospadias, isolated dextrocardia, hypoplastic ribs, an ectopic kidney and spina bifida occulta. Although some of the clinical features of this patient are seen in VATER association and sacrococcygeal dysgenesis, the presence of dextrocardia, facial dysmorphism, radial, renal and vertebral anomalies preclude these diagnoses.

Balance and gait in total hip replacement: a pilot study

OBJECTIVE

Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects.

DESIGN

A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group.

RESULTS

Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living.

CONCLUSIONS

Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.

Effect of 7beta-hydroxycholesterol on cellular redox status and heat shock protein 70 expression in macrophages

The proatherogenic effects of oxidized low-density lipoproteins are attributed to oxysterols, particularly 7beta-hydroxycholesterol. In the present study, we have examined the effect of 7beta-hydroxycholesterol on cellular redox status and heat shock protein 70 (hsp70) expression. Murine peritoneal macrophages were incubated for 24 hours with increasing concentrations of 7beta-hydroxycholesterol (0-25 microg/ml). Intracellular reduced glutathione levels decreased and oxidized glutathione levels increased, thus increasing the redox ratio. Hsp70 expression in macrophages decreased in a dose-dependent fashion. It is suggested that 7beta-hydroxycholesterol exerts oxidative stress on macrophages and makes them more susceptible to its proatherogenic effects by impairing the cellular defense system consisting of antioxidants and stress proteins.

Synchronizing N release from organic residues: opportunities for integrated management of N

In intensive cropping systems, mineral nitrogen (N) fertilizers represent the largest component of the N cycle because the indigenous N supply is not adequate. The requirement for mineral fertilizer may be reduced with the use of organic nutrient sources. A more realistic use of organic matter, particularly in sub-Saharan Africa due to limited amounts and availability, is the combined use of organic nutrient sources and mineral fertilizers. The beneficial effects of integrated use of inorganic fertilizers and organic manures on improved nutrient recoveries, soil moisture retention, cation exchange capacity, and erosion control have been reported. However, there are as many reports indicating negligible benefits or even disadvantages of combining nutrient sources on crop production. This is not surprising given the combination of organic residue sources, soils, climatic, crops, and management factors that influence nutrient dynamics. The most widely accepted function of organic materials is improving the nutrient availability to crops by supplying N. The key to both improving efficiency of N use and reducing N losses is synchronization of N supply from soil, biological N2 fixation, organic residues, and inorganic fertilizers with the crop N demand. Organic materials are not magic; N losses also result from their use. Controlling N release from organic sources depends on their nutrient content and quality, soil properties, and the environmental and management factors. This paper will synthesize the information generated from integrated nutrient management trials in sub-Saharan Africa and the Philippines. Management strategies based on an organic resources database and a dynamic soil-crop simulation model are used to identify organic sources as N fertilizers or soil amendments. The decision support tools are also used to attain optimum synchrony between release from organic sources and soils with crop N demand.

Comparative biochemical and immunocytochemical studies reveal differences in the effects of Clostridium perfringens enterotoxin on polarized CaCo-2 cells versus Vero cells

Since most in vitro studies exploring the action of Clostridium perfringens enterotoxin (CPE) utilize either Vero or CaCo-2 cells, the current study directly compared the CPE responsiveness of those two cell lines. When CPE-treated in suspension, both CaCo-2 and Vero cells formed SDS-resistant, CPE-containing complexes of approximately 135, approximately 155, and approximately 200 kDa. However, confluent Transwell cultures of either cell line CPE-treated for 20 min formed only the approximately 155-kDa complex. Since those Transwell cultures also exhibited significant (86)Rb release, approximately 155-kDa complex formation is sufficient for CPE-induced cytotoxicity. Several differences in CPE responsiveness between the two cell lines were also detected. (i) CaCo-2 cells were more sensitive when CPE-treated on their basal surface, whereas Vero cells were more sensitive when CPE-treated on their apical surface; those sensitivity differences correlated with CPE binding the apical versus basolateral surfaces of these two cell lines. (ii) CPE-treated Vero cells released (86)Rb into both Transwell chambers, whereas CaCo-2 cells released (86)Rb only into the CPE-containing Transwell chamber. (iii) Vero cells express the tight junction (TJ) protein occludin but (unlike CaCo-2 cells) cannot form TJs. The ability of TJs to affect CPE responsiveness is supported by the similar effects of CPE on Transwell cultures of CaCo-2 cells and Madin-Darby canine kidney cells, another polarized cell forming TJs. Confluent CaCo-2 Transwell cultures CPE-treated for >1 h formed the approximately 200-kDa CPE complex (which also contains occludin), exhibited morphologic damage, and had occludin removed from their TJs. Collectively, these results identify CPE as a bifunctional toxin that, in confluent polarized cells, first exerts a cytotoxic effect mediated by the approximately 155-kDa complex. Resultant damage then provides CPE access to TJs, leading to approximately 200-kDa complex formation, internalization of some TJ proteins, and TJ damage that may increase paracellular permeability and thereby contribute to the diarrhea of CPE-induced gastrointestinal disease.

Pretransitional optical activity of short-pitched chiral nematic liquid crystals

We have developed, using the de Gennes theory of short-range orientational order in the isotropic phase, a closed-form expression for the temperature dependence of the pretransitional optical activity of chiral nematics. Detailed calculations are included and the results are expressed in a form that can be easily tested experimentally. The theoretical predictions are supported by experimental data.

Influence of 7beta-hydroxycholesterol on glutathione status and nitric oxide production in macrophages: in vitro studies

Incubation of murine peritoneal macrophages with 7beta-hydroxycholesterol (7beta-OH) for 24 hr led to dose-dependent reduction in cellular glutathione content as well as nitrite levels in the medium. Treatment with an inorganic form of selenium, sodium selenite which is a potent antioxidant, elevated the cellular glutathione levels and decreased nitrite levels. Our results suggest that 7beta-OH may exert its pro-atherogenic effect by inhibiting glutathione synthesis and nitric oxide production by macrophages present in the arterial wall and thus, impair the cellular antioxidant defense system.

Cyclin-dependent kinase (cdk) inhibitors/cdk4/cdk2 complexes in early stages of mouse mammary preneoplasia

The level of circulating ovarian hormones (estrogen and progesterone) alone or in combination with pituitary hormones have a potent mitogenic impact in the normal mammary gland, and they also play a pivotal role in the development and progression of mammary carcinoma. The differential effects of hormones on the molecular components of cyclin-dependent kinase (cdk) complexes in mammary epithelium of the hormone-dependent ductal outgrowth line, EL11, and the hormone-independent alveolar outgrowth line, TM2L, were the focus of this study. The two outgrowth lines, which represent early stages in mammary hyperplasia, were compared with normal mammary gland at different hormonal conditions: control, hormone stimulated by pituitary isograft, and hormone depleted by ovariectomy. Hormonal stimulation by a pituitary isograft resulted in DNA synthesis and lobuloalveolar development of normal mammary ducts, DNA synthesis but no lobuloalveolar development in the EL11 ductal outgrowth, and no changes either in DNA synthesis or in lobuloalveolar morphology in the TM2L outgrowth. The levels of cdk4- and cyclin D1-associated kinase activities were correlated with cell proliferation in only the alveolar phenotypes (i.e., in only hormonally stimulated normal virgin gland and in alveolar mammary outgrowth), whereas cyclin D2-dependent kinase activity was correlated with cell proliferation in only the alveolar preneoplasia. p16(INK4a) and p21(Cip1) protein levels were decreased at the earliest stages of preneoplasia, i.e., at immortalization, and were independent from changes in cyclin D1, which occurred later in preneoplasia. Although all cdk inhibitors changed in concordance with hormonal status reflected by proliferation levels, p27(Kip1) was the only cdk inhibitor that was up-regulated at the earliest stages of preneoplasia and may have a unique role in blocking alveolar differentiation in response to the loss of one or more of the cell cycle-negative regulators. We hypothesize that up-regulation of p27(Kip1) prevents immortalized ductal outgrowths (EL11) from progressing to the neoplastic state, even under hormonal stimulation.

Postoperative complications and visual results in uniocular pediatric traumatic cataract

BACKGROUND AND OBJECTIVES

This study was prospectively carried out to evaluate the postoperative complications and visual results following posterior chamber intraocular lens (PCIOL) implantation in children with unilateral traumatic cataract.

PATIENTS AND METHODS

We prospectively evaluated 40 children, 12 years or younger, with traumatic cataract (blunt trauma, n = 22 eyes, repaired penetrating eye injury, n = 18 eyes) undergoing PCIOL implantation with a minimum follow-up period of one year. Children with posterior segment ocular injury were excluded.

RESULTS

The postoperative complications were significantly higher in the penetrating eye injury group as compared to blunt trauma group (ie, pupillary capture 44.44% vs 9.09%, posterior capsulotomy rate 83.33% vs 40.90% and IOL decentration 27.77% vs 4.54%). The final visual acuity was 6/12 or better in 38.8% and 86.36% of eyes with penetrating eye injury and blunt trauma, respectively.

CONCLUSION

Extracapsular cataract extraction (ECCE) with PCIOL implantation in traumatic cataract following blunt trauma results in better visual outcome and fewer complications compared to penetrating eye injury if the posterior segment is not involved.

Multiple vasculogenic disabilities : a challenge in rehabilitation

A 37 year old male presented with left hemiplegia, left below knee amputation, right partial foot amputation and claudication pain. The limitations in the rehabilitation management in such a high-risk patient are multiplied. The appreciable benefits from supervised rehabilitation and judicious goal setting can help in improving the functional status and retard the disease progression in such patients. This study highlights that coexisting cerebrovascular, coronary and peripheral vascular diseases can pose a real challenge and can result in multiple disabilities.

Se-methylselenocysteine activates caspase-3 in mouse mammary epithelial tumor cells in vitro

Se-methylselenocysteine (MSC) inhibits mouse mammary epithelial tumor cell (TM6) growth. When synchronized TM6 cells were exposed to 50 microM MSC, either for 30 minutes or continuous, the 116 kDa poly(ADP-ribose)polymerase (PARP) was cleaved to an 85 kDa fragment indicative of cells undergoing apoptosis. The earliest cleaved PARP appears at 24 hr time point followed by elevated levels of 85 kDa fragment at 34 hr and 48 hr time points when the cells were exposed to continuous treatment with MSC. Results also showed that MSC increased caspase-3 activity at 24 hr time point. In addition, continuous treatment with MSC induced DNA fragmentation at 34 hr and 48 hr time points with caspase-3 gene expression moderately increased at 16 hr and 24 hr time points. Caspase-6 and -8 were also involved in the MSC-induced apoptosis but to a lesser extent. These results suggest that MSC mediates cleavage of PARP and apoptosis by activating one or more caspases in synchronized TM6 cells and the events are dependent on the duration of treatment.

Issues related to disability in India: a focus group study

BACKGROUND

Systematic research into disability has been scarce, especially from India, even though an estimated 5% of the population may have significant disability due to physical disorders. Depression as a common psychiatric disorder affects about 3%-5% of the population. Thus, the impact of disability related to physical, mental and substance use disorders is enormous and it influences resource allocation and policy planning.

METHODS

The issues relating to disability were addressed through a qualitative multicentered study. Focus groups were conducted at three sites in Chennai, Bangalore and Delhi on three themes: (i) parity, stigmatization and social participation; (ii) current practices and needs; and (iii) the General Disability Model as proposed by the World Health Organization. The focus groups were homogeneous and included members from six categories of participants: individuals with physical disability, individuals with mental disability, individuals with alcohol/drug-related disability, family members of mentally disabled persons, family members of physically disabled persons and health professionals. In all, 118 groups were conducted with a mean (SD) group size of 8.6 (1.6).

RESULTS

Patients with mental and alcohol/drug-related disability were more discriminated against than those with physical disability. Awareness regarding the existing laws and social programmes was uniformly poor across the three centres. Stigmatization was a major reason for under-utilization of the meagre resources available. There was poor awareness of the Disability Act, 1996. The consumers felt more comfortable with the earlier terms of 'handicap' and 'impairment'.

CONCLUSIONS

The study has implications for policy planning, clinical decision-making and social behaviour. Awareness of the laws, facilities and programmes needs to be increased, especially regarding the Disability Act, 1996 among consumers as well as health professionals. More disability-friendly facilities are required.

Multiple eccrine spiradenomas in zosteriform distribution in a child

A 9-year-old boy presented with asymptomatic papulonodular lesions on the left half of the chin of 3-years duration. On examination he had small papular lesions on the left chin varying in size from 1 to 5 mm. An additional lesion on the margin of the lip was 14 mm in diameter. The overlying skin was normal. Lesions were firm, nontender, and fixed to the skin. Histopathologic examination of the biopsy specimen revealed characteristic features of eccrine spiradenoma. A literature search produced reports of 10 cases of linear/zosteriform spiradenoma. Of these, five were in children or adolescents. We report this patient because of the rare occurrence of this presentation.

CaCo-2 cells treated with Clostridium perfringens enterotoxin form multiple large complex species, one of which contains the tight junction protein occludin

The previous model for the action of Clostridium perfringens enterotoxin (CPE) proposed that (i) CPE binds to host cell receptor(s), forming a small ( approximately 90 kDa) complex, (ii) the small complex interacts with other eucaryotic protein(s), forming a large ( approximately 160 kDa) complex, and (iii) the large complex triggers massive permeability changes, thereby inducing enterocyte death. In the current study, Western immunoblot analysis demonstrated that CPE bound to CaCo-2 human intestinal cells at 37 degrees C forms multiple large complex species, with apparent sizes of approximately 200, approximately 155, and approximately 135 kDa. These immunoblot experiments also revealed that occludin, an approximately 65-kDa tight junction protein, is present in the approximately 200-kDa large complex but absent from the other large complex species. Immunoprecipitation studies confirmed that occludin physically associates with CPE in large complex material and also indicated that occludin is absent from small complex. These results strongly suggest that occludin becomes associated with CPE during formation of the approximately 200-kDa large complex. A postbinding association between CPE and occludin is consistent with the failure of rat fibroblast transfectants expressing occludin to bind CPE in the current study. Those occludin transfectants were also insensitive to CPE, strongly suggesting that occludin expression is not sufficient to confer CPE sensitivity. However, the occludin-containing, approximately 200-kDa large complex may contribute to CPE-induced cytotoxicity, because nontoxic CPE point mutants did not form any large complex species. By showing that large complex material is comprised of several species (one containing occludin), the current studies indicate that CPE action is more complicated than previously appreciated and also provide additional evidence for CPE interactions with tight junction proteins, which could be important for CPE-induced pathophysiology.

Visual outcome following cataract surgery in rural punjab

In a cluster sample survey in rural areas of Punjab visual outcome after cataract surgery was assessed. Three hundred patients (428 cataract operated eyes) were included in the study from 24 sampled villages. The mean age at cataract extraction was 61.70 +/- 9.82 years. The average interval since the cataract surgery was 7.05 +/- 5.86 years (range 0.11-32 years). Of the 428 operated eyes, 72 (16.82%) were blind (VA < 3/60), 162 (37.85%) had low visual acuity (VA 3/60-< 6/18) and 194 (45.33%) eyes gained good visual acuity (VA > or = 6/18). Cataract surgery related complications were the principal causes leading to blindness in 50 of 72 eyes; these included corneal oedema, (17/72;23.3%), retinal detachment (14/72;19.4%), and aphakic glaucoma (13/72;18.05%). This study emphasizes the need to improve the qualitative aspect of cataract surgery including long-term follow up in rural India.