Ag-doped phosphate bioactive glasses: thermal, structural and in-vitro dissolution properties

Ag doped-bioactive phosphate glasses were processed by traditional melt quenching technique with the concentration of Ag

Trans-anal endoscopic microsurgery for internal rectal prolapse

Internal rectal prolapse can lead to obstructed defecation, faecal incontinence and pain. In treatment of frail or technically difficult patients, a perineal approach is often used, such as a Delorme’s or a STARR. However, in case of very high take-off prolapse, these procedures are challenging if not unsuitable. We present trans-anal endoscopic microsurgery as surgical option for management of this uncommon type of rectal prolapse in specific cases.

Reduction of microalbuminuria in type-2 diabetes mellitus with angiotensin-converting enzyme inhibitor alone and with cilnidipine

The aim of our study was to find out the antiproteinuric effect of enalapril angiotensin-converting enzyme (ACE inhibitor) alone or in combination with cilnidipine in patients with type-2 diabetes mellitus. The study was conducted on 71 patients with type-2 diabetes mellitus patients with hypertension and microalbuminuria. They were divided into two groups randomly as follows: Group I (enalaprilalone, n = 36) and Group II (enalapril with cilnidipine, n = 35). In both the groups, baseline 24 h urinary albumin was estimated and was repeated every 3 months upto 1-year. After 1-year follow-up, reduction in microalbuminuria was found to be greater in Group II. In Group I microalbuminuria came down by 25.68 ± 21.40 while in Group II it reduced by 54.88 ± 13.84 (P < 0.001). We conclude that in diabetic population, cilnidipine has an additive effect in microalbuminuria reduction over and above the well-proven effect of ACE inhibitors.

Systematic review of the relationship between artificial sweetener consumption and cancer in humans: analysis of 599,741 participants

BACKGROUND

The effect of artificial sweetener consumption on cancer risk has been debated in animal models for over four decades. To further investigate this relationship, this study aims to synthesise results from several of the most recent studies in humans.

METHODS

An online literature search was performed in MEDLINE from 2003 to 2014 using Ovid, PubMed, Web of Science, and Scopus using keywords 'artificial', 'sweetener' and 'cancer'. Ninety-two results were then manually assessed for eligibility. Studies were included if the relationship between artificial sweeteners and cancer was their central hypothesis, and if they adjusted for age, gender, smoking status and body mass index. Extracted data included study design, patient characteristics, outcome measure and results.

RESULTS

In the five publications that satisfied the inclusion criteria, significant direct associations with artificial consumption were found for laryngeal (odds ratio, OR 2.34, 95% CI: 1.20-4.55), urinary tract tumours (OR 2.12, 95% CI: 1.22-3.89), non-Hodgkin lymphoma in men (RR 1.31, 95% CI: 1.01-1.72), multiple myeloma in men (RR 2.02, 95% CI: 1.20-3.40) and leukaemia (RR 1.42, 95% CI: 1.00-2.02). Inverse relationships were found in breast (OR 0.70, 95% CI: 0.54-0.91, p trend = 0.015) and ovarian (OR 0.56, 95% CI: 0.38-0.81, p trend < 0.001) cancers.

CONCLUSION

The statistical value of this review is limited by the heterogeneity and observational designs of the included studies. Although there is limited evidence to suggest that heavy consumption may increase the risk of certain cancers, overall the data presented are inconclusive as to any relationship between artificial sweeteners and cancer.

Bilateral adrenalectomy for Cushing's syndrome: Pros and cons

AIM

To assess the outcome of patients undergoing bilateral adrenalectomy for Cushing's syndrome (CS).

METHODS

All patients who underwent bilateral adrenalectomy for CS at the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences hospital between 1991 and 2013 were included. Medical records were reviewed to obtain patient characteristics and follow-up data.

RESULTS

Twenty-seven patients were studied. Mean age was 28.74 ± 12.95 years (range 9-60), male:female ratio was 1.7:1. About half that is, 48.19% were of Cushing's disease (failed trans-sphenoidal surgery [TSS]), 37.04% were of ectopic CS (ECS), and 14.81% were of CS due to bilateral adrenal pathology. Median follow-up period was 80.5 months. Before surgery, 74.1% patients had body mass index > which after surgery declined to <25 in 75% of them. Hypertension was present in 85.2% and after surgery resolved in 40%. Diabetes mellitus was present in 44.4% and after surgery resolved in 33% of them. Hirsutism and proximal muscle weakness were present in 55.6% and 70.4% patients, respectively, and after surgery improved markedly in all patients. Adrenal crisis developed in 36.3% and Nelson's syndrome in 41.7% patients during follow-up. Three patients died in perioperative period while three succumbed to the disease during follow-up. Two patients developed recurrence of endogenous cortisol production during the follow-up period.

CONCLUSIONS

Bilateral adrenalectomy is a valid treatment option for palliating severe symptoms in Pituitary Cushing's with failed TSS and unlocalized ECS but the procedure is curative for CS due to bilateral adrenal disease. Overall morbidity and mortality is higher than other endocrine operations. Co-morbidities tend to be more severe and are a risk factor for mortality during the time patient survives.

Laparoscopic rectopexy is feasible and safe in the emergency admission setting

AIM

External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse.

METHOD

A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed.

RESULTS

Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse.

CONCLUSION

Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities.

Advanced therapeutic options in pulmonary hypertension: who, what and when?

Pulmonary hypertension (PH) is the common hemodynamic consequence of various pathophysiologic mechanisms. Since the publication of the most current American and European guidelines (2009) new agents were introduced into the clinical arena while data regarding former drugs has been substantiated. The therapeutic endeavor of evaluating new therapies for PH targets patients based on their PH type and symptom severity with the hope to demonstrate hemodynamic and functional benefits along with reduction in morbidity and mortality. Although patients' outcomes (predominantly among type I and IV) have improved, the hemodynamic and symptomatic benefit is modest and not uniform. The purpose of this review is to objectively assess the benefits of the currently available dedicated agents. It is our hope that with early detection and careful individual titration of new combination therapy in expert hands, we will better serve a larger proportion of our PH patients.

Ocular myocysticercosis: an unusual case of ptosis

BACKGROUND

Cysticercosis is common in endemic countries like India. It can have various clinical manifestations depending on the tissue involved. It refers to a parasitic infestation by Cysticercus cellulosae, the larval form of the pork tapeworm or Taenia solium.

OBJECTIVE

To report an unusual case of ocular cysticercosis involving the levator palpebrae superioris and superior rectus muscle of the right eye.

CASE DESCRIPTION

A young, male adult was diagnosed by Magnetic Resonance Imaging (MRI) scan of the skull and orbit to have right-sided ocular cysticercosis. The patient was treated with oral prednisolone and albendazole, to which he showed a significant improvement.

CONCLUSION

Ocular myocysticercosis can be diagnosed by MRI and be treated medically with steroid and albendazole.

Inpatient resource utilization, disease severity, mortality and insurance coverage for patients hospitalized for hepatitis C virus in the United States

Although the incidence of new hepatitis C virus (HCV) infection has fallen, HCV-related complications are on the rise. Our aim was to assess and describe the 2005-2009 national inpatient mortality and resource utilization trends for patients with HCV. Data from the National Inpatient Sample (NIS) and the National Hospital Discharge Survey (NHDS) between 2005 and 2009 were analyzed. Included were all adult hospital discharges with HCV-related ICD-9 codes. Incremental hospital charge, in-hospital mortality and length of stay (LOS) were estimated using n = 1000 bootstrap replicates clustered by unique hospital identifier. A total of 123 939 (0.38%) discharges were related to HCV (primary or secondary diagnosis). In-hospital mortality increased from 1.7% (2005) to 2.6% (2009) (P < 0.001). Inflation-adjusted charges increased 2% annually from 2005 ($16 455 ± $570) to 2009 ($17 532 ± $1007, P = 0.029). This increase occurred despite the average LOS (5 days) and hospital costs ($6500) remaining stable while at the same time, hospital-to-hospital transfer admissions and disposition to home health care increased. HCV-related hepatocellular carcinoma predicted longer hospital stay and death; older age predicted death; and receiving more procedures predicted higher hospital costs. The percentage of patients with private insurance significantly decreased (4.7%), while government-sponsored insurance and uninsured increased by 2.5% and 2.1%, respectively (P < 0.05). Uninsured patients had a 49%-72% greater chance of dying during hospitalization than those with government-sponsored insurance. HCV-related inpatient mortality and resource utilization have increased. HCC was the largest predictor for mortality and resource utilization. These data are consistent with the rising clinical and societal burden of chronic hepatitis C in the United States.

The association of hepatitis C virus infection and post-liver transplant diabetes: data from 17 000 HCV-infected transplant recipients

BACKGROUND

Hepatitis C virus (HCV) is associated with metabolic manifestations including insulin resistance and diabetes through various mechanisms. Whether HCV infection is associated with an increased risk of post-transplant diabetes in liver transplant recipients is unclear.

AIM

To assess the association of HCV infection with post-transplant diabetes.

METHODS

All liver transplant recipients infected with hepatitis C (exposed) and hepatitis B (HBV) (controls) with post-transplant follow-up from the Scientific Registry of Transplant Recipients (2003-2012) were included.

RESULTS

A total of 17 121 HCV patients and 1450 HBV controls were included in this observational study. Subjects with HCV were more likely to be overweight and obese at transplant, but the rate of pre-transplant diabetes of 13.7% was similar to HBV (P > 0.05). Post-transplant, 32.5% of HCV patients and 27.5% of HBV patients had diabetes (P < 0.0001). This difference was observed starting as early as 6 months post-transplant: 22.5% HCV and 18.9% HBV (P = 0.0043). With longer follow-up, both the cumulative and incidental risks of developing post-transplant diabetes were consistently higher in HCV patients. In particular, by 5 years post-transplant, both the relative risk of having diabetes [1.18 (1.08-1.29), P = 0.0002] and the hazard ratio for time to developing diabetes [1.27 (1.15-1.41), P < 0.0001] were significantly higher in HCV patients compared to HBV patients. In multivariate analysis, after adjustment for confounders including the use of immunosuppressants, hepatitis C infection was independently associated with developing post-transplant diabetes: aHR = 1.55 (1.34-1.79), P < 0.0001.

CONCLUSION

Hepatitis C infection is associated with a higher risk of post-transplant diabetes that persists up to 5 years post-transplant.

Hyperimmunoglobulin syndrome due to CD40 deficiency: possibly the first case from India

Hyperimmunoglobulin M (HIGM) type 3 due to CD40 deficiency is a very rare syndrome. Only 16 cases have been reported thus far. The clinical presentation is very variable. We present the first case of this rare disorder from India. The case is of a two-and-a-half-year-old female, with a history of repeated episodes of skin infections and diarrhea since birth. Laboratory evaluation revealed elevated absolute lymphocyte count and an absolute neutrophil count (ANC) of 1026/mm3. The lymphocyte subset analysis showed normal absolute counts of Natural Killer (NK) cells and elevated absolute counts of T-cells (CD4 and CD8) and B-cells. The serum immunoglobulin estimation showed low levels of IgG, IgA, IgE and an elevated level of IgM. The CD154 analysis was normal and expression of CD40 was absent on the B-cells. Molecular analysis showed a novel mutation, with deletion of 3bp (AAG) [p.Glu107GlyfsX84] in the homozygous state, in the CD40 gene. Thus the patient was diagnosed as HIGM type 3. The parents were screened and counseled regarding prenatal diagnosis at the time of next pregnancy.

The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections

AIM

The aim of this study was to evaluate the incidence of incisional hernia formation after laparoscopic and open surgery for colorectal cancer.

METHOD

A retrospective analysis was conducted of 1057 colorectal cancer resection cases (289 laparoscopic, 768 open) performed in a single national laparoscopic training centre between January 2006 and December 2011. Clinical notes and serial computed tomography scans were reviewed, with any incisional hernia including those at a surgical incision, port site, stoma and stoma closure site identified and the size of the defect measured.

RESULTS

The overall incisional hernia rate was 14.8%. There was no significant difference between the open and laparoscopic groups (14.4% vs 15.9%, P = 0.566). Excluding stoma-related hernia, 10.7% of the open group developed a surgical wound hernia, and 11.1% of the laparoscopic group developed a hernia at a port site, extraction site or surgical midline incision. There was no statistical difference between the two groups (P = 0.853). The defects were smaller in the laparoscopic group (P < 0.005). There were significantly more parastomal hernias in the laparoscopic group (40%) than in the open group (12.7%, P < 0.001).

CONCLUSION

The incidence of incisional hernia formation was similar after laparoscopic or open surgery for colorectal cancer. Parastomal hernia was more frequent after laparoscopic surgery.

Wnt3a mitigates acute lung injury by reducing P2X7 receptor-mediated alveolar epithelial type I cell death

Acute lung injury (ALI) is characterized by pulmonary endothelial and epithelial cell damage, and loss of the alveolar–capillary barrier. We have previously shown that P2X7 receptor (P2X7R), a cell death receptor, is specifically expressed in alveolar epithelial type I cells (AEC I). In this study, we hypothesized that P2X7R-mediated purinergic signaling and its interaction with Wnt/β-catenin signaling contributes to AEC I death. We examined the effect of P2X7R agonist 2′-3′-O-(4-benzoylbenzoyl)-ATP (BzATP) and Wnt agonist Wnt3a on AEC I death in vitro and in vivo. We also assessed the therapeutic potential of Wnt3a in a clinically relevant ALI model of intratracheal lipopolysaccharide (LPS) exposure in ventilated mice. We found that the activation of P2X7R by BzATP caused the death of AEC I by suppressing Wnt/β-catenin signaling through stimulating glycogen synthase kinase-3β (GSK-3β) and proteasome. On the other hand, the activation of Wnt/β-catenin signaling by Wnt3a, GSK-3β inhibitor, or proteasome inhibitor blocked the P2X7R-mediated cell death. More importantly, Wnt3a attenuated the AEC I damage caused by intratracheal instillation of BzATP in rats or LPS in ventilated mice. Our results suggest that Wnt3a overrides the effect of P2X7R on the Wnt/β-catenin signaling to prevent the AEC I death and restrict the severity of ALI.

Diagnostic approach to primary immunodeficiency disorders

Primary immunodeficiency disorders (PIDs) are a heterogeneous group of inherited disorders that affect different components of the immune system. There are more than 150 different disorders which have been described till date. Despite major advances in the molecular characterization of PIDs over the last 20 years, many patients remain undiagnosed or are diagnosed too late with severe consequences. Recognizing different clinical manifestations of PID is the first most important step. It should be followed by use of appropriate diagnostic tools from a vast number of investigations available. This review will focus on important presenting features of PID and laboratory approach for diagnosis of suspected cases of PID.

Systematic review with meta-analysis: non-alcoholic steatohepatitis - a case for personalised treatment based on pathogenic targets

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an umbrella term, which encompasses simple steatosis and non-alcoholic steatohepatitis (NASH). The entire spectrum of NAFLD has been associated with metabolic syndrome. NASH is associated with increased mortality compared with that of the general population. Many therapeutic options for NASH have been studied. However, there is very little evidence supporting the efficacy of most regimens for the treatment of NASH.

AIM

To provide a review focusing on the current therapeutic options available for patients with NASH as well as to briefly introduce possible future interventions.

METHODS

A MEDLINE, Pubmed and Cochrane Review database search using a combination of keywords, which included non-alcoholic fatty liver disease, non-alcoholic hepatic steatosis, NAFLD, NASH, treatment, therapeutics, vitamin E, orlistat and bariatric surgery. An overall summary of the articles was developed for each section of discussion in this review.

RESULTS

NASH associated with metabolic syndrome can progress advanced fibrosis and cirrhosis. Weight loss and lifestyle modification have been shown to improve NASH. Other medications used for weight loss and metabolic syndrome have been evaluated, such as orlistat, metformin and thiazolidinediones. Alternative regimens using ursodeoxycholic acid, statins and probiotics as well as bariatric surgery have been evaluated, but have not been recommended as first-line treatment for NASH. Vitamin E for NASH patients without diabetes seems to be promising. The lack of effective treatment for NASH suggests the heterogeneity of patients presenting with the NASH phenotype. The best treatment strategy for these patients may be to identify their pathogenic target and develop personalised treatment protocols.

CONCLUSIONS

Currently, there are few options available for the management of NASH. Future targeted treatment strategies based on the pathogenic pathways may be needed to develop effective treatment for patients with NASH.

Cloning, expression, purification, crystallization and preliminary X-ray studies of argininosuccinate lyase (Rv1659) from Mycobacterium tuberculosis

The last enzyme in the arginine-biosynthesis pathway, argininosuccinate lyase, from Mycobacterium tuberculosis has been cloned, expressed, purified and crystallized, and preliminary X-ray studies have been carried out on the crystals. The His-tagged tetrameric enzyme with a subunit molecular weight of 50.9 kDa crystallized with two tetramers in the asymmetric unit of the orthorhombic unit cell, space group P2(1)2(1)2(1). Molecular-replacement calculations and self-rotation calculations confirmed the space group and the tetrameric nature of the molecule.

The impact of chronic hepatitis C on resource utilisation and in-patient mortality for Medicare beneficiaries between 2005 and 2010

BACKGROUND

As baby boomers age, chronic hepatitis C (CHC) will become increasingly important in Medicare eligible group.

AIM

To evaluate trends in Medicare resource utilisation for CHC.

METHODS

We analysed the Medicare in-patient and out-patient data from 2005 to 2010. For each patient, all claims with CHC as a principal diagnosis were added up and yearly CHC-related spending was calculated.

RESULTS

A total of 48,880 out-patient claims for 21,655 CHC patients and 4884 hospital admission claims for 3092 patients were included. The number of in-patient (1.5-1.6/year) or out-patient (2.2-2.3/year) visits per patient did not change over time, nor did the demographic characteristics of the CHC population. The majority of this population was eligible for Medicare based on disability and the average number of diagnoses per in-patient claim (from 8.11 in 2005 to 8.60 in 2010) and per out-patient claim (from 2.18 in 2005 to 2.71 in 2010) increased (both P < 0.0001). The average total yearly spending per patient increased in the out-patient setting from $488 in 2005 to $584 in 2010 (P = 0.0132) and did not change in the in-patient setting (from $22,245 in 2005 to $23,383 in 2010, P = 0.14). In the multivariate analysis, the number of diagnoses and conditions per claim and the number of in-patient or out-patient procedures per year were the important independent predictors of increased resource utilisation.

CONCLUSIONS

Most Medicare beneficiaries with chronic hepatitis C who sought in-patient or out-patient care in 2005-2010 had received Medicare for disability. Although the total resource utilisation did not change, the proportion of patient's responsibility increased.

Mortality associated with alcohol-related liver disease

BACKGROUND

Excessive alcohol use has been reported to be responsible for 80 000 annual deaths in the United States. However, the exact cause of death related to the excessive use of alcohol has not been fully explored.

AIM

To assess the effect of alcoholic liver disease (ALD) on all-cause, liver-related and cardiovascular mortality using population-based data.

METHODS

Data were obtained from the Third National Health and Nutrition Examination Survey (NHANES III) Linked Mortality Files. Alcohol consumption was estimated as grams per day. Multivariate Cox proportional hazards model was utilised to assess the effects of ALD on follow-up time to mortality from all causes, cardiovascular disease and liver disease.

RESULTS

A total of 8,306 participants were included [ALD (n = 148)]. Mortality follow-up data were available for a median time of 178.27 months. Participants with ALD had increased risk for liver-related mortality [adjusted hazard ratios or aHR 7.06 (2.09-23.79)], but not for overall mortality [aHR 1.14 (0.70-1.85)] or cardiovascular mortality [aHR 0.61 (0.11-3.25)].

CONCLUSION

Alcoholic liver disease increases the risks for liver-related mortality but not for cardiac or overall mortality.

Can yoga be used to treat gastroesophageal reflux disease?

Yoga methods including Pranayama are the best ways to prevent many diseases and their progression. Even though, Yoga is widely practiced, its effects on certain medical conditions have not been studied or reported. Gastroesophageal reflux disease (GERD) is one of them. GERD is extremely common condition requiring frequent consumption of over-the-counter or prescribed proton pump inhibitors (PPI). In severe symptoms of GERD and in the presence of multiple etiologies, PPIs are insufficient to relieve the symptoms of gastric reflux. Regular and proper use of the Yoga along with PPI can control the severe symptoms of GERD and can avoid or delay the necessity of invasive procedures. This evidence-based case report focuses on the effects of Yoga on GERD. Our case report showed that regular practice of Kapalbhati and Agnisar kriya along with PPI, patients with hiatal hernia had improvement in severe symptoms of GERD, which were initially refractory to PPI alone.

Knowledge about infection is the only predictor of treatment in patients with chronic hepatitis C

HCV is the leading cause of cirrhosis and liver cancer in the U.S. The Center for Disease Control (CDC) has recently recommended 'Birth Cohort Screening' of the U.S. Adult population to reduce the future burden of undiagnosed HCV infections in the U.S. Our aim was to assess independent predictors of receiving treatment in a cohort of HCV-infected patients. The Hepatitis C follow-up questionnaires of the National Health and Nutrition Examination Surveys (NHANES) conducted from 2001 to 2010 were used. The NHANES participants who tested positive for HCV RNA were followed by CDC 6 months after initial testing with questions related to their awareness of their infection and history or intention to receive treatment. A total of 500 NHANES participants tested positive for HCV RNA and were targeted for follow-up. Of these, only 203 had completed the follow-up questionnaire (response rate of 40.6%). Of these, only 101 (50%) knew about their HCV positivity before NHANES, and from them, only 34 (17%) had received treatment. In multivariate analysis, prior knowledge about their HCV infection in HCV-positive individuals was independently associated with receiving routine care from a doctor or HMO, with higher income, female gender, being in poor or fair health and not consuming excessive amounts of alcohol. On the other hand, the knowledge about HCV infection was the only independent predictor of receiving anti-HCV treatment (odds ratio 6.14). Knowledge about having HCV infection is the only independent predictor of receiving treatment. Therefore, birth cohort screening of the U.S. General population could lead to wider identification of HCV and potentially better management of the future burden of HCV and its complications.

A case of isolated cutaneous Rosai-Dorfman-Syndrome

Rosai-Dorfman Syndrome (RDD) is a rare, benign, self-limiting disorder which is characterized by the non-malignant proliferation of distinctive histiocytic cell within lymphatic system. RDD has been described as a dynamic entity in the spectrum of histiocytosis with non-Langerhans cell histiocytosis at one end and Langerhans cell histiocytosis at the other. The exact etiology of this disease is uncertain despite widespread search for infectious or immunological reasons. We present a case of purely cutaneous Rosai-Dorfman Syndrome presenting as abdominal wall swelling.

KEYWORDS

Rosai-Dorfman Disease, Lymphoma.

Varying positions and anthropometric measurement of supraorbital and supratrochlear canal/foramen in adult human skulls

The supratrochlear and supraorbital notches and foramina have been studied in 312 adult skulls of known age and sex. Out of them, in males 49.4% had bilateral supraorbital notches and 13.5% had bilateral foramina, 18.91% had a notch on one side and a foramen on the other side. Bilateral supratrochlear notch was present in 5.4% skulls, 9.65% skulls had bilateral supratrochlear canals and 8.49% had unilateral supratrochlear foramina/ notch on one or the other side. In females, 32% had bilateral supraorbital foramina and 30.18% had bilateral supraorbital notches. 37.7% had unilateral foramen/notch. Supratrochlear canal was present in 13.2% skulls on one or the other side. Bilateral notch was present in 2 skulls (3.77%) only. There was a significant difference between the frequency of supraorbital foramina and notches in males whereas there was no significant difference between the two in females. The distances of the notches/foramina from the midline and also from the temporal crest were measured. The distance of the supraorbital and supratrochlear foramen from the supraorbital rim was measured. There was no significant difference between the two genders. Knowledge of the anatomy of the region is important for those doing forehead and brow lift surgery in order to avoid injuring the neurovascular bundles passing through these notches and foramina, hence the gender wise present study. The methods of study and clinical relevance are discussed.