Changing picture of acute kidney injury in pregnancy: Study of 259 cases over a period of 33 years

The incidence of acute kidney injury (AKI) in pregnancy is declining in developing countries but still remains a major cause of maternal and fetal morbidity and mortality. The aim of the study was to analyze the changing trends in pregnancy related AKI (PR-AKI) over a period of thirty-three years. Clinical characteristics of PR-AKI with respect to incidence, etiology and fetal and maternal outcomes were compared in three study periods, namely 1982-1991,1992-2002 and 2003-2014. The incidence of PR-AKI decreased to 10.4% in 1992-2002, from 15.2% in 1982-1991, with declining trend continuing in 2003-2014 (4.68%).Postabortal AKI decreased to 1.49% in 2003-2014 from 9.4% in 1982-1991of total AKI cases. The AKI related to puerperal sepsis increased to 1.56% of all AKI cases in 2003-2014 from 1.4% in 1982-1991. Preeclampsia/eclampsia associated AKI decreased from 3.5% of total AKI cases in 1982-1991 to 0.54% in 2003-2014. Pregnancy associated – thrombotic microangiopathy and acute fatty liver of pregnancy were uncommon causes of AKI. Hyperemesis gravidarum associated AKI was not observed in our study. Incidence of renal cortical necrosis (RCN) decreased to 1.4% in 2003-2014 from 17% in 1982-1991.Maternal mortality reduced to 5.79% from initial high value 20% in 1982-1991. The progression of PR-AKI to ESRD decreased to1.4% in 2003-2014 from 6.15% in 1982-1991. The incidence of PR-AKI has decreased over last three decades, mainly due to decrease in incidence of postabortal AKI. Puerperal sepsis and obstetric hemorrhage were the major causes of PR-AKI followed by preeclampsia in late pregnancy. Maternal mortality and incidence and severity of RCN have significantly decreased in PR-AKI. The progression to CKD and ESRD has decreased in women with AKI in pregnancy in recent decade. However, the perinatal mortality did not change throughout study period.

Premedication in an autistic, combative child: Challenges and nuances

Children with autistic spectrum disorders are often encountered in anesthesia practice mainly for outdoor procedural sedation or anesthesia in endoscopy and magnetic resonance imaging suites. We describe a case of a 7-year-old autistic boy who required management of dental caries. He had a phobia to intravenous cannulation, displayed increasing anxiety and became combative on the day of surgery. With parental involvement and distraction, we succeeded in giving oral midazolam by concealing it, with the intent of avoiding intramuscular injection or unnecessary restraint. Lack of knowledge about the medical condition of such a patient can lead to inadequate preoperative preparation and use of restraint on the patient, which might cause anxiety or panic attacks in the operative room. To effectively manage children with special needs one needs to have clear guidelines on the management of uncooperative children, involve parents perioperatively, plan ahead with an emphasis on perioperative analgesia and sometimes incorporate the ethical use of restraint.

A first record of the Lined Wrasse Anampses lineatus Randall, 1972 (Perciformes: Labridae) in the Gulf of Mannar, Tamil Nadu, India

Lined wrasse Anampses lineatus Randall was recorded off the coast of Tuticorin (Gulf of Mannar), Tamil Nadu, India for the first time. It is easily distinguished by the presence of pale longitudinal lines on the body following scale rows. Broad pale white and black color patch at the base of caudal fin is distinct. Morphological description of A. lineatus is provided based on the present material along with detailed distribution records; habitat and closely related species were also discussed.

Anesthetic management of a parturient with varicella presenting for cesarean delivery

Varicella (chicken pox) infection is associated with a significant risk of maternal and fetal morbidity and mortality. The choice of anesthetic technique, either neuraxial or general anesthesia, in such patients remains controversial. Anesthetic management depends not only on the extent of disease involvement and associated complications, but also on the indication for cesarean delivery. We present the anesthetic management of a 25-year-old parturient with acute varicella infection who underwent emergency cesarean delivery under spinal anesthesia. The risks and benefits of neuraxial anesthesia in the setting of varicella are discussed.

Discordance between ROTEM® clotting time and conventional tests during unfractionated heparin–based anticoagulation in intensive care patients on extracorporeal membrane oxygenation

We hypothesised that ROTEM® (Basel, Switzerland) INTEM® (ROTEM, Basel, Switzerland) clotting time (CT) would have good agreement with activated partial thromboplastin time (aPTT) in determining whether a dose adjustment should be made to the unfractionated heparin (UFH) infusion in patients on extracorporeal membrane oxygenation. All patients treated with extracorporeal membrane oxygenation over a five-year period were included for data analysis. Retrospective analysis was performed of prospectively collected data points, wherein aPTT, activated CT and ROTEM was performed simultaneously to monitor UFH–based anticoagulation. Two hundred data points were available for analysis. Turnaround time was shortest for activated CT followed by ROTEM and aPTT. Despite achieving therapeutic aPTT targets, the majority (>50%) of INTEM CT results were within normal limits. The aPTT and INTEM CT results correlated weakly (r=0.31, 95% confidence interval [0.17, 0.43]) and there was no agreement between the directional changes of aPTT and INTEM CT results on successive days (χ2 = 2.33, P=0.17). Due to relative insensitivity, INTEM CT–guided UFH titration was estimated to result in a 289% increase in incidence of up-titration, over aPTT–guided titration. The INTEM CT results (r=0.36, 95% confidence interval [0.23, 0.48]) correlated weakly with UFH infusion rates. The UFH infusion rate only explained 13% variability in INTEM CT values. While haemorrhagic complications were frequent, no major clotting complications were encountered. Our results demonstrated that aPTT and INTEM CT do not provide equivalent information to guide UFH infusion rate titration during extracorporeal membrane oxygenation. Our study suggests caution regarding the use of ROTEM for guiding UFH–based anticoagulation as it may lead to excessive UFH exposure.

The synthesis, characterization, removal of toxic metal ions and in vitro biological applications of a sulfanilamide–salicylic acid–formaldehyde terpolymer

SASF terpolymer possess great applications for removal of heavy metal ions from environmental and industrial wastes.

Influence of physicochemical and nutritional factors on bacterial diversity in mangrove sediments along the southwest coast of Tamilnadu, India

The present study was undertaken to investigate the diversity of mangrove-associated bacterial genera at Manakudy estuary, Southwest coast of India. The root and rhizosphere sediments of both mangrove and their associated plants were collected from chosen area. Results inferred that the maximum nutrients, THB density, and diversity indices were recorded in rhizosphere and root sample of Avicennia officinalis. Altogether, 258 bacterial strains were isolated from the chosen mangrove samples and screened for nitrogen fixing and phosphate solubilizing ability. Screened result inferred that, 36.43 % isolates had nitrogen fixing and 29.45 % isolates had phosphate solubilizing ability. Here, the genus Bacillus spp. (21.71 %) was the most dominant genera. The bacterial diversity indices, i.e., univariate analysis showed remarkable variation between the chosen samples; however, maximum diversity indices was registered by rhizosphere and root sample of A. officinalis. The 95 % confidence interval and ellipse showed that samples were well mendacious within AvTD and VarTD. Likewise, the multivariate analysis like similarity percentage was good discriminator from 16.64 to 100 % by Bray-Curtis dissimilarity. The prinicipal component analysis (PCA) showed marked variation between the tested bacterial communities. Cluster analysis and non-metric multi-dimensional scaling (MDS) were grouped by Bray-Curtis similarity index which strongly evidence that the rhizosphere and root samples of A. officinalis were highly diversified in the study area.

Lactobacillus fermentum NCIMB 5221 and NCIMB 2797 as cholesterol-lowering probiotic biotherapeutics: in vitro analysis

Cardiovascular and coronary artery disease risk are correlated with cholesterol levels and are significant health concerns. Current cholesterol-lowering approaches includes lifestyle and diet modifications, as well as statins which presents numerous shortcomings. The probiotic bacteria, Lactobacillus fermentum NCIMB 5221 and NCIMB 2797, have demonstrated cholesterol-lowering potential in animal studies. However, there is a lack in understanding the mechanism(s) behind these observed effects. The goal of this work is to investigate, in vitro, the cholesterol-lowering mechanisms of these two strains. To determine the cholesterol-lowering mechanisms, probiotic cholesterol assimilation, colon epithelial adhesion and inhibition of cholesterol uptake by colon epithelial (Caco-2) cells were investigated. L. fermentum NCIMB 2797 (P=0.012) and NCIMB 5221 (P=0.003) assimilated cholesterol and their cell surface hydrophobicity was 70.30±8.85% and 55.60±2.59%, respectively. Both L. fermentum strains showed no significant impact (P>0.05) on Caco-2 cell viability. Of most interest, Caco-2 pre-exposure to L. fermentum NCIMB 5221 significantly decreased (P=0.015) cholesterol uptake, with 85.98±2.07% uptake compared to the untreated cells. Similarly, L. fermentum NCIMB 2797 probiotic cells significantly decreased (P=0.019) cholesterol uptake by Caco-2 cells, with 86.45±1.71% uptake observed compared to the control cells. The results demonstrate that L. fermentum NCIMB 5221 and L. fermentum NCIMB 2797 have the potential via various modes of action to lower cholesterol. Additional studies are required to understand the mechanism(s) of action behind probiotic cholesterol assimilation and behind the cholesterol uptake inhibition by colon epithelial cells.

Bimetallic PdAg nanoparticle arrays from monolayer films of diblock copolymer micelles

The self-assembly technique provides a highly efficient route to generate well-ordered structures on a nanometer scale. In this paper, well-ordered arrays of PdAg alloy nanoparticles on flat substrates with narrow distributions of particle size (6-7 nm) and interparticle spacing (about 60 nm) were synthesized by the block copolymer micelle approach. A home-made PS-b-P4VP diblock copolymer was prepared to obtain a micellar structure in toluene. Pd and Ag salts were then successfully loaded in the micellar core of the PS-b-P4VP copolymer. A self-assembled monolayer of the loaded micelles was obtained by dipping the flat substrate in the solution. At this stage, the core of the micelles was still loaded with the metal precursor rather than with a metal. Physical and chemical reducing methods were used to reduce the metal salts embedded in the P4VP core into PdAg nanoparticles. HRTEM and EDX indicated that Pd-rich PdAg alloy nanoparticles were synthesized by chemical or physical reduction; UV-visible spectroscopy observations confirmed that metallic PdAg nanoparticles were quickly formed after chemical reduction; XPS measurements revealed that the PdAg alloy nanoparticles were in a metallic state after a short time of exposure to O2 plasma and after hydrazine reduction.

Non-diabetic renal disease in type 2 diabetes mellitus: Study of renal - retinal relationship

Diabetic nephropathy (DN) has become the leading cause of end-stage renal disease worldwide. Non-diabetic renal disease (NDRD), is known to occur in diabetic patients. The renal and retinal relationship in type 2 diabetes mellitus (T2DM) with nephropathy is not uniform. This study was carried to study the histological spectrum of nephropathy in type 2 diabetic patients with proteinuria and its relationship with diabetic retinopathy (DR). Total 31 (males - 26; females - 5) proteinuric type 2 diabetic patients were studied. Average age of patients was 50.7 years. Nephrotic syndrome was noted in 21 (67.7%) patients. Overall, isolated DN, NDRD and NDRD superimposed on DN (mixed lesion) were observed in 12 (38.7%), 13 (41.9%) and 6 (19.4%) cases, respectively. DR was absent in 21/31 (67.7%) cases. The spectrum of nephropathy in patients without DR included: DN in 6 (28.57%), NDRD in 12 (57.14%) and mixed lesion in 3 (14.29%). Kidney histology in patients with DR (n-10) revealed DN in 6 (60%), NDRD in 1 (10%) and mixed lesion in 3 (30%) patients. Thus, absence of DR favors NDRD but does not exclude DN because isolated DN was noted in 28.57% cases in absence of DR. Similarly biopsy proven NDRD (pure NDRD; 10% and mixed lesion; 30%) was noted in 40% of cases in presence of DR. In summary, patients with T2DM had higher incidence of NDRD. DR is less frequent (32.3%) in type 2 diabetes and is a poor predictor of type of nephropathy. Hence, renal biopsy is essential for precise diagnosis of nephropathy in patients with T2DM.

Investigation of probiotic bacteria as dental caries and periodontal disease biotherapeutics

Oral diseases, specifically dental caries and periodontal disease, are characterised by increases in pathogenic microorganisms, increased demineralisation and increased inflammation and levels of inflammatory markers. Despite the therapeutic strategies, oral diseases have elevated prevalence rates. Recent work has demonstrated that probiotic bio-therapeutics can decrease oral pathogen counts, including caries-causing Streptococcus mutans and oral inflammation. The aim of this work was to investigate putative probiotic bacteria, selected for S. mutans inhibition and for their oral health-promoting characteristics. The probiotic bacteria were screened for S. mutans inhibition, probiotic bacteriocin activity, salivary pH modulation, probiotic nutrient (sucrose) competition, probiotic co-aggregation with S. mutans, bacterial attachment to oral epithelial keratinocytes, bacterial nitric oxide production and bacterial antioxidant activity. The results indicate that Lactobacillus reuteri strains NCIMB 701359, NCIMB 701089, NCIMB 702655 and NCIMB 702656 inhibited S. mutans to non-detectable levels (<10 cfu/ml). L. reuteri strains also demonstrated the highest antioxidant capacity of the tested strains (7.73-13.99 µM Trolox equivalents), suggesting their use as both caries and periodontal disease therapeutics. Although Lactobacillus fermentum NCIMB 5221 inhibited S. mutans at lower levels, it significantly buffered the pH (4.18) of saliva containing S. mutans, co-aggregated with S. mutans (10.09%), demonstrated high levels of sucrose consumption (138.11 mM) and successfully attached to gingival epithelial cells (11%). This study identified four L. reuteri strains and one L. fermentum strain to be further investigated as oral disease biotherapeutics.

Acute kidney injury in patients with human immunodeficiency virus infection

Acute kidney injury (AKI) is an important cause of hospitalization and morbidity in human immunodeficiency virus (HIV)-positive patients. However, the data on AKI in such patients is limited. The aim of the present study was to analyze the incidence, causes and outcome of AKI in HIV-positive patients from our antiretroviral therapy centre. All HIV-positive patients were evaluated for evidence of clinical AKI. AKI was noted in 138/3540 (3.9%) patients. Of 138 AKI patients, 96 (69.6%) had acquired immuno deficiency syndrome and 42 (30.4%) were HIV seropositive. Majority of AKI patients belonged to AKI network (AKIN) Stage II (42%) or III (48.5%) at presentation. Prerenal, intrinsic and postrenal AKI were noted in 53.6%, 44.2% and 2.2% of cases, respectively. Hypovolemia (44.2%) and sepsis (14.5%) contributed to AKI in vast majority of cases. AKI was multifactorial (volume depletion, sepsis and drugs) in 39% of patients. Acute tubular necrosis (ATN) was the most common intrinsic lesion. Acute interstitial nephritis and diffuse endocapillary proliferative glomerulonephritis were noted in five and two cases, respectively. In-hospital mortality was 24.64%. Lower CD4 count, decreased serum albumin level and Stage 4 WHO disease were associated with higher mortality. At 3 months or more follow-up complete recovery of renal function, chronic kidney disease Stage 3-5 and progression to end stage renal disease were noted in 58.69%, 14.5% and 2.2% of cases, respectively. Thus, prerenal factors and ischemic ATN were the most common cause of AKI in HIV-infected patients. Recovery of renal function was seen in 59% of cases, but AKI had high in-hospital mortality.

Impact of killer immunoglobulin-like receptor-human leukocyte antigens ligand incompatibility among renal transplantation

Killer immunoglobulin-like receptor (KIR) gene shows a high degree of polymorphism. Natural killer cell receptor gets activated once they bind to self-human leukocyte antigens (HLAs) with specific ligand. KIR gene and HLA ligand incompatibility due to the presence/absence of KIR in the recipient and the corresponding HLA ligand in the allograft may impact graft survival in solid organ transplantation. This study evaluates the effect of matches between KIR genes and known HLA ligands. KIR genotypes were determined using sequence specific primer polymerase chain reaction. Presence of certain KIR in a recipient, where the donor lacked the corresponding HLA ligand was considered a mismatch. The allograft was considered matched when both KIR receptor and HLA alloantigen reveald compatibility among recipient and donor. The data revealed better survival among individuals with matched inhibitory KIR receptors and their corresponding HLA ligands (KIR2DL2/DL3-HLAC2, KIR3DL1-HLABw4). On the contrary, no adverse effect was seen for matched activating KIR receptors and their corresponding HLA ligands. One of the activating gene KIR2DS4 showed risk (P = 0.0413, odds ratio = 1.91, 95% confidence interval = 1.02-3.57) association with renal allograft rejection. We conclude that the presence of inhibitory KIR gene leads to better survival; whereas activating motifs show no significant role in renal allograft survival.

Ex vivo electrical impedance measurements on excised hepatic tissue from human patients with metastatic colorectal cancer

Point-wise ex vivo electrical impedance spectroscopy measurements were conducted on excised hepatic tissue from human patients with metastatic colorectal cancer using a linear four-electrode impedance probe. This study of 132 measurements from 10 colorectal cancer patients, the largest to date, reports that the equivalent electrical conductivity for tumor tissue is significantly higher than normal tissue (p < 0.01), ranging from 2-5 times greater over the measured frequency range of 100 Hz-1 MHz. Difference in tissue electrical permittivity is also found to be statistically significant across most frequencies. Furthermore, the complex impedance is also reported for both normal and tumor tissue. Consistent with trends for tissue electrical conductivity, normal tissue has a significantly higher impedance than tumor tissue (p < 0.01), as well as a higher net capacitive phase shift (33° for normal liver tissue in contrast to 10° for tumor tissue).