pCONUS 2 and pCONUS 2-HPC for the treatment of wide-necked intracranial aneurysms: Periprocedural, 6-month, and early 2-year follow-up outcomes

BACKGROUND/PURPOSE

pCONUS 2 and pCONUS 2-HPC are novel neck-bridging devices designed to support endovascular coil occlusion of wide-necked intracranial bifurcation aneurysms. This study summarises periprocedural outcomes, 6-month, and early 2-year follow-up results following its introduction in an interventional neuroradiology centre.

MATERIALS/METHODS

This prospective, single-arm study assessed 20 aneurysms treated over a 40 month time period from time of procedure to 2 years post-procedure. Data collected included patient demographics, aneurysm features, and intraprocedural, 6-month, and 2-year post-procedural complications and angiographic features.

RESULTS

The mean age of the cohort was 59+-SD 7.7 years. 16 unruptured aneurysms were treated (pCONUS 2 13/16, pCONUS 2-HPC 3/16) and 4 ruptured aneurysms were treated with pCONUS 2-HPC. Unruptured cases received dual antiplatelet therapy pre- and post-procedure while ruptured cases received single antiplatelet therapy. 9/20 aneurysms were located at the MCA bifurcation and 7/20 at the basilar tip. The remaining 4 aneurysms were at various bifurcations in the anterior circulation. 11/20 were small (<10mm) and 9/20 were large (10-25mm). There was one periprocedural complication: a retroperitoneal bleed. There were no post-procedural intracranial complications or at 6-months follow-up. At 6 months, satisfactory occlusion was achieved in 94% of cases (15/16). There was one delayed death at 2-year follow-up from an unrelated cause.

CONCLUSION

pCONUS 2 and pCONUS 2-HPC have excellent short and medium-term safety profiles and clinical outcomes with no procedure-related mortality or morbidity and good occlusion rates at 6-month follow-up. The use of pCONUS 2-HPC with single antiplatelet therapy is feasible and did not cause any complications.

Glutamic acid decarboxylase (anti-GAD) & tissue transglutaminase (anti-TTG) antibodies in patients with thyroid autoimmunity

BACKGROUND & OBJECTIVES

Several autoimmune disorders have been reported to be associated with autoimmune thyroiditis and may coexist with other organ-specific autoantibodies. The aim of the present study was to evaluate the presence of tissue transglutaminase (anti-TTG) and glutamic acid decarboxylase (anti-GAD) antibodies in patients suffering from autoimmune thyroiditis as diagnosed by anti-thyroid peroxidase (anti-TPO) antibodies, which may indicate high risk for developing celiac disease or type 1 diabetes mellitus.

METHODS

Five thousand children and 2800 adults were screening as part of a general health examination done on a voluntary basis in four different parts of Delhi. A total of 577 subjects positive for anti-TPO antibody constituted the cases. Equal number of age and sex matched anti-TPO antibody negative controls were randomly selected from the same cohort to form paired case control study. The cases and controls were further divided into two groups as follows: group-1 (children and adolescent <18 yr), group-2 (adults >18 yr). Serum samples of cases and controls were analysed for thyroid function test (FT3, FT4, and TSH), anti-TTG and anti-GAD antibodies.

RESULTS

A total of 1154 subjects (577 cases and 577 controls) were included in this study. Hypothyroidism was present in 40.2 per cent (232) cases compared to only 4.7 per cent (27) in controls (P<0.001). Anti-TTG and anti-GAD antibodies were present in 6.9 and 12.5 per cent subjects among cases compared to 3.5 per cent (P=0.015) and 4.3 per cent (P=0.001) in controls, respectively. Only anti-GAD antibody were significantly positive in cases among children and adolescents (P =0.0044) and adult (P=0.001) compared to controls. Levels of anti-TTG and anti-GAD antibodies increased with increasing titre of anti-TPO antibody.

INTERPRETATION & CONCLUSIONS

Our findings showed high positivity of anti-GAD and anti-TTG antibodies among subjects with thyroid autoimmunity. It is, therefore, important to have high clinical index of suspicion for celiac disease or type 1 diabetes mellitus in patients with autoimmune thyroiditis.

Bone health in healthy Indian population aged 50 years and above

One thousand six hundred healthy subjects aged more than 50 years, residing in Delhi, were evaluated for bone mineral metabolic parameters. High prevalence of osteoporosis (35.1% subjects) was observed in this population. Bone mineral density (BMD) correlated positively with body mass index (BMI) and negatively with PTH levels. No correlation was observed with serum 25(OH)D levels.

INTRODUCTION

To assess the bone health status in elderly Indians and compare peripheral DXA (pDXA) with central DXA in evaluation of osteoporosis.

METHODS

The study involved 1,600 healthy subjects more than 50 years of age residing in Delhi, India, who underwent anthropometric, biochemical, and hormonal evaluation. BMD was measured by DXA at lumbar spine, hip, and distal radius; and by pDXA at forearm and calcaneum.

RESULTS

Seven hundred ninety-two males and 808 postmenopausal females, with a mean age of 57.67 ± 9.46 years were evaluated. Osteoporosis was present in 35.1% subjects (M-24.6%, F-42.5%) and osteopenia in 49.5% (M-54.3%, F-44.9%). Prevalence of osteoporosis increased with age in females, but not in males. BMD at all sites, except distal radius, was positively correlated with BMI (r=0.037, p=0.14). Total body BMD was negatively correlated with alkaline phosphatase (r= -0.184, p<0.00001) and PTH levels (r= -0.099, p<0.00001), respectively. No significant correlation was observed between serum 25(OH)D levels and BMD at any site. BMD at forearm and calcaneum, measured using pDXA, showed strong positive correlation with BMD measured by central DXA. pDXA had sensitivity of 88%, specificity of 55%, and negative and positive predictive values of 89% and 52%, respectively, at T-score -2.5 at peripheral sites compared to central DXA.

CONCLUSIONS

A high prevalence of osteoporosis was observed in elderly Indian subjects. pDXA has high negative predictive value, making it a useful tool in population screening for osteoporosis.

Vitamin D status in healthy Indians aged 50 years and above

INTRODUCTION

There is widespread prevalence of vitamin D deficiency from new-born to infancy, childhood and adult male and females (non-pregnant, pregnant and lactating). However, there is limited information of the vitamin D status in elderly Indians.

MATERIAL AND METHODS

The study was carried in 1346 healthy subjects more than 50 years of age residing in Delhi, India. These subjects, who were divided in two groups: Group-1 (50-< 65 years) and Group-2 (> or = 65 years), underwent anthropometric, biochemical and hormonal evaluation for vitamin D status Bone mineral density was measured by dual X-ray absorptiometry.

RESULTS

There were 643 males and 703 females, with a mean age of 58.0 +/- 9.5 years (range 50-84 years). Vitamin D deficiency [VDD, serum 25(OH)D levels < 20 ng/ml) was present in 1228 (91.2%) and Vitamin D insufficiency [VDI, serum 25(OH)D levels 20-< 30 ng/ml] in 92 (6.8%). There was no significant difference in prevalence of either VDD or VDI between two age groups and sexes. Serum 25(OH)D levels were negatively correlated with PTH levels (r -0.027, p <0.00001) and BMI (r -0.128, p 0.05). Prevalence of secondary hyperparathyroidism increased from 14.1% to 43.1% from VDI to severe VDD. PTH levels started rising at vitamin D level < 30 ng/ml. However, more than 50% of subjects with severe VDD had PTH levels within normal range. High prevalence of osteopenia (50.2%) and osteoporosis (31.2%) was observed in this population.

CONCLUSION

Hypovitaminosis D is universal above the age of 50 years in north India. Absence of a PTH response was observed in more than 50% of individuals with VDD, the cause of which merits further evaluation. Normal bone mass was observed in only 18.6% of study subjects.

Vitamin D nutritional status of exclusively breast fed infants and their mothers

BACKGROUND

Vitamin D nutrition has a profound effect on the development of an infant. Vitamin D status of mothers and their infants are closely correlated. While hypovitaminosis D has emerged as a significant public health problem across all age groups, there is limited information of this condition in lactating mothers and their breast fed infants.

AIM

To evaluate the vitamin D status of lactating mothers and their breast fed infants.

SUBJECTS AND METHODS

180 healthy lactating mothers and exclusively breast fed infants, 2-24 weeks old, were recruited for the study. The mother-infant pairs underwent concurrent clinical, biochemical and hormonal evaluation for calcium-vitamin D-PTH axis.

RESULTS

The mean serum 25(OH)D values in lactating mothers was 27.2 +/- 14.6 nmol/l (10.9 +/- 5.8 ng/ml), while that of their infants was 28.9 +/- 20.8 nmol/l (11.6 +/- 8.3 ng/ml). Serum 25(OH)D levels <25 nmol/l (10 ng/ml) were found in 47.8% of the mothers and 43.2% of the infants. Among these, elevated PTH levels (>54 pg/ml) were seen in 59.3% of the mothers and 69.6% of the infants. A highly significant negative correlation was found between serum 25(OH)D and PTH in mothers (r = -0.480, p = 0.01) and their infants (r = -0.431, p = 0.01). A strong positive correlation was seen of 25(OH)D levels in mother-infant pairs (r = 0.324, p = 0.001).

CONCLUSIONS

A high prevalence of vitamin D deficiency was found in lactating mothers and their exclusively breast fed infants. Infants born to mothers with hypovitaminosis D had 3.8 times higher risk of developing hypovitaminosis D as compared to those born to mothers with normal vitamin D levels.

Comparison of clinical and histopathological evaluation of tonsils in pediatric and adult patients

The aim of this study was to determine clinical features that could predict the presence of tonsillar malignancy in children and adults. A retrospective review of the histopathologic reports of the children, who underwent tonsillectomy (753 cases) during the past 16 years (January 1991-December 2006) in a busy district general hospital, was undertaken. We compared the results to the pre-operative data of the patients, for risk factors of malignancy. Such proposed risk factors were tonsillar asymmetry, palpable firmness, visible lesions, neck adenopathy, history of malignancy, and systemic symptoms. The same data (history, risk factors and histopathologic results) were reviewed for an adult group (>16 years old, 1,027 cases) who underwent tonsillectomy during that period, and the results of the two groups were compared. In the pediatric group only one case was diagnosed as lymphoma (0.13%) and the rest as chronic inflammation (47%), reactive tonsil tissue (26%), lymphoid hyperplasia (19%) and actinomycosis (8%). In the lymphoma case, the diagnosis was suspected preoperatively by history and clinical manifestations. In the adult group, there were 21 cases of malignancy out of 1,027 cases (2.04%), again with one or more positive risk factors in the pre-surgery history. Based on our review, it is concluded that histopathology of tonsillectomy is not necessary in children unless there is clinical suspicion based on preoperative findings. A protocol based on proposed risk factors which may be predictive of possible malignancy can be used as a guide to intraoperative histology.

Pott′s puffy tumor following an insect bite

Pott's puffy tumor, a feature of osteomyelitis of the frontal bone, is a rare entity, especially in adults. Sir Percival Pott originally described this condition as a complication of trauma to the frontal bone. This is also a recognized complication of fronto-ethmoidal sinusitis. We present a rare case of Pott's puffy tumor caused by an insect bite presenting initially as a preseptal cellulitis and explore its pathogenesis and management.

Clinical performance indicators at hysterectomy

The short-term complications of hysterectomy in 184 women have been documented over 12 months against a panel of clinical performance indicators in a district general hospital. One hundred and fifty-nine operations (159/184, 86.4%) were performed by the abdominal route; 25/184 (13.6%) by the vaginal route. Clinical indications for hysterectomy varied from menorrhagia (75/184, 40.7%) to Stage III/IV endometriosis (10/184, 5.4%). Clinical performance indicators (cPI) were triggered in 32/184 (17.4%) cases; 19/ 184 (10.3%) triggered a single performance indicator, 9/184 (4.9%) triggered two performance indicators and 4/184 (2.2%) triggered three performance indicators. Combining the number of hysterectomies performed per annum (HYST 1), with the proportion of cases triggering three or more clinical performance indicators (HYST 2) and the rate of hysterectomy for histologically normal uteri weighing less than 120 g excluding genital prolapse (HYST 3) provides a profile of the operation for comparison with other clinical services.

Mechanical forces imposed on echinoid eggs during spawning: mitigation of forces by fibrous networks within egg extracellular layers

Many echinoderms spawn large numbers of eggs in rapid spawning bouts directly into the water column. During spawning, the eggs pass from the gonad along a narrow oviduct and through a rigid gonopore before reaching the water. As the eggs traverse this pathway, they are exposed to shear stress induced by the development of a velocity gradient within the fluid formed by the eggs. In some species, the diameter of the eggs is larger than the diameter of the gonopore. In these cases, the eggs also experience strain resulting from compression of the egg as it passes through the relatively small gonopore. The magnitude of shear stress experienced by eggs differs among species depending upon the viscosity of the eggs. The degree of strain experienced by eggs differs among species depending upon the relative sizes of the egg and gonopore and also changes within species as they grow. Recent evidence suggests that these forces have the propensity to damage eggs, thereby reducing their fertilizability, or to destroy them. Experimental evidence shows that the jelly coat around the eggs can protect them from shear stresses and reduce the strain imposed on them under a compressive force. Echinoderm eggs are surrounded by a jelly coat that has a composite structure of irregularly arranged fibrous networks embedded in a jelly matrix. These fibrous networks have characteristics that are similar to those of engineered and biological materials that are known to reduce the transmission of mechanical forces to other structures. Given this similarity to other materials, three possible mechanisms for the action of the jelly coat may be identified. First, the apparent viscosity of the eggs of echinoids declines as the rate at which they are sheared during spawning increases. This reduction in viscosity with increasing shear rate (shear-thinning) may, in part, be due to the structure of the jelly coat and its resultant non-Newtonian nature. Second, experimental evidence indicates that the jelly coat preferentially deforms under a compressive load, reducing the transmission of that load to the egg. Third, the jelly (but not the fibers in the coating) may deform in a nearly viscous manner. In this case, the fibers may serve to provide an elastic ‘backbone’ to the layer and remain in place to stiffen the outer layer of the egg. The composite structure of the jelly coat and the morphology of the fibrous network are likely to be critical to all these mechanisms.

HLA-DQ and TAP2 genes in patients with insulin-dependent diabetes mellitus

We examined the prevalence of HLA-DRB1, DQB1, DQA1 and TAP2 genes in children with insulin-dependent diabetes mellitus (type 1 diabetes). These HLA and TAP2 alleles were identified by dot-blot analysis of polymerase chain reaction (PCR)-amplified genomic DNA with sequence-specific oligonucleotide probes. The results show that those DQB1 alleles, which carry non-aspartic acid at position 57, in conjunction with DQA1 alleles carrying arginine at position 52, are strongly associated with susceptibility to type 1 diabetes. The prevalence of the TAP2* 0201 allele in diabetic patients was significantly lower than that in normal controls. Analysis of the data suggests that DQ alleles have the primary association with type 1 diabetes and that the association of TAP2 alleles with the disease is secondary.

HLA-DPB1 alleles in patients with rheumatoid arthritis

The distribution of HLA-DPB1 alleles was studied in 94 adult Caucasian RA patients (65 = seropositive, 29 = seronegative) and 40 normal controls. The DPB1 alleles were defined by oligonucleotide typing of polymerase chain (PCR)-amplified genomic DNA. The prevalence of the DPB1*0402 allele was higher in seropositive RA patients and DPB1*0201 was higher in seronegative RA patients. These differences were not significant, however. It is likely that DPB1 alleles do not play an important role in susceptibility to RA.

Seronegative rheumatoid arthritis and HLA-DR4

OBJECTIVE

To investigate the prevalence of HLA-D region antigens in patients with seronegative rheumatoid arthritis (RA).

METHODS

The distribution of HLA-D region antigens was studied in 33 patients with seronegative RA. All patients were followed for at least 3 years, during which tests for IgM rheumatoid factor were negative on at least 3 occasions. HLA-D region antigens were defined by serological and molecular techniques (oligonucleotide typing).

RESULTS

Our data demonstrate that DR4 was significantly (p < 0.021) increased in patients (45.5%) compared to normal controls (22.9%). Although the prevalence of DR1 was essentially the same in patients (15.2%) as in healthy controls (14.3%), the frequency of DR1 and/or DR4 was significantly (p < 0.018) increased in patients (60.6%) compared to healthy subjects (35.7%). The prevalence of remaining DR antigens and of DQ and DP specificities in patients with seronegative RA was not different from that in healthy controls.

CONCLUSION

Our results together with those published by other investigators suggest that both seropositive and seronegative RA are associated with DR4 and may therefore share the same immunogenetic bases.

Immunogenetics of polymyalgia rheumatica

The distribution of HLA-D region antigens was studied in 17 patients with well-documented polymyalgia rheumatica (PMR). HLA-D region antigens were defined by the oligonucleotide typing of polymerase chain reaction (PCR)-amplified genomic DNA. The results demonstrate that the prevalence of DR4 was significantly higher (p < 0.0002; RR = 8.10) in patients (70.6%) compared to normal controls (22.9%), and the frequency of DR1 and/or DR4 in patients (82.4%) was also higher (p < 0.0006; RR = 8.40) than that in normal healthy controls (35.7%). Of the subtypes of DR4,Dw13 was significantly higher (p < 0.002; RR = 9.30) in patients (29.4%) than in normal controls (4.3%). However, these data must still be confirmed by other investigators. The distribution of the remaining DR antigens and of the DQ and DP alleles in patients did not differ significantly from those in controls. The results suggest immunogenetic similarity between PMR and late onset rheumatoid arthritis in elderly populations.

Allogeneic blood transfusion-induced enhancement of tumor growth: two animal models showing amelioration by leukodepletion and passive transfer using spleen cells

Allogeneic blood transfusions have been reported to induce immunomodulation in recipients of blood products. While the mechanism(s) of this immunomodulatory effect is unknown, it has been suggested that this effect of allogeneic blood transfusions could adversely affect patients with a malignant disorder. These concerns have been supported by a number of nonrandomized, mainly retrospective, clinical studies which indicate that allogeneic blood transfusions can adversely affect prognosis following the surgical treatment of oncology patients. Recently, we have shown that allogeneic blood transfusions enhance primary tumor growth and increase metastatic pulmonary nodule formation in inbred mice. The tumor growth-promoting activity of allogeneic blood transfusions was studied also using outbred rabbits. In this present study, we demonstrate that the tumor growth-promoting effect of allogeneic blood transfusions is mediated by donor leukocytes and that this effect can be abolished by their removal before transfusion. We show also that the allogeneic blood transfusion tumor growth-promoting effect can be passively transferred to naive animals (both mice and rabbits) using spleen cells from allogeneically transfused animals. In these experiments, numbers of metastatic pulmonary nodules were significantly increased in both mice and rabbits that had received spleen cells from allogeneically transfused animals compared with those that had received spleen cells from syngeneically transfused animals, or from animals that had been transfused with leukodepleted allogeneic blood.