Managing Diabetic Foot Complications During COVID-19 Lockdown in India: A Survey

To understand the management of diabetic foot complications by the Diabetic Foot Research India (DFRI) members during the lockdown period. An online survey link was created in "Survey Monkey", and the link was sent to all the members of Diabetic Foot Research India (DFRI) who are staying in different parts of India and data were collected from May 2020 to June 2020. The survey included questions on the type of consultation they provided to their patients, management of a patient with an active foot ulcer, and the various difficulties encountered by the doctors during the lockdown. A total of 33 diabetologists from all over the country participated in this survey. Among them, 26 doctors had attended to active diabetic foot infection at the time of the online survey. Almost three fourth of the (n = 24; 72.7%) doctors recorded difficulties during the inpatient consultations. Difficulty in regular follow-ups, the facility's workforce shortage was reported to be a significant concern. In managing active foot ulcer cases, 15 doctors (45.5%) opted for in-person consultation in their hospital as they felt the infection cannot be handled over a tele-consultation. Amputation was not performed by 78.7% of doctors, 15% (n = 5) of the doctors performed less than five amputations, and 6% (n = 2) of the doctors performed more than five amputations during the lockdown period. In the case of SMBG (Self-monitoring blood glucose) values, the regularity of patients reporting the values varied significantly. Only 8 (24.2%) doctors reported that 75% of their patients regularly shared their SMBG values while all the others mentioned that their patients were not performing SMBG regularly. Most of the physicians were able to manage the diabetic foot complications by tele-consultation during the lockdown and only a few asked the patients to get hospitalized for surgical intervention. All doctors should recommend SMBG to continuously monitor patients' blood glucose levels and prevent complications of hyperglycemia, particularly during pandemic situations.

Precision of Michigan Neuropathy Screening Instrument (MNSI) Tool for the Diagnosis of Diabetic Peripheral Neuropathy Among People with Type 2 Diabetes-A Study from South India

Diabetic peripheral neuropathy (DPN) is one of the risk factors for foot-related complications among people with type 2 diabetes mellitus (T2DM). Hence, we aimed to validate the Michigan Neuropathy Screening Instrument (MNSI) tool against biothesiometer with a cut-off value of ≥25 V and also to determine the cut-off point of MNSI score for the diagnosis of diabetic neuropathy among people with T2DM in India. A cross-sectional study was conducted among 357 people with T2DM in a tertiary care centre for diabetes in Chennai, South India. The eligible study participants underwent testing with a biothesiometer and the MNSI tool was administered. The patient version tool of MNSI was translated to the local language, Tamil. The MNSI scores (1, 1.5, 2, and 2.5) were compared with biothesiometer value. For the MNSI scores of less than 1, 1.5, 2, and 2.5, sensitivities were 97.6%, 97.6%, 96.8%, and 77.8% and specificities were 76.6%, 77.9%, 85.7%, and 88.3% respectively. The cut-off value of MNSI score was derived as two with AUC of 0.934. The sensitivity was 96.8% and the specificity was 85.7% with 89.6% accuracy. The high sensitivity indicates the positive cases are diagnosed correctly. There is no validated tool available for detection of DPN in Indian population. The Indian version of MNSI tool was found to be effective for screening diabetic neuropathy among people with T2DM. The MNSI tool was found to be reliable, convenient, and non-invasive for diagnosis of DPN and can be used in routine clinical settings.

Phytochemical screening and evaluation of antioxidant, total phenolic and flavonoid contents in various weed plants associated with wheat crops

This study explores the antioxidant activity, phytochemical screening, total phenolic and flavonoids contents in the extracts of four locally available weeds plants namely Convolvulus arvensis, Chenopodium murale, Avena fatua and Phalaris minor with different solvents. The antioxidant activities of these extracts were determined via various in-vitro methods such as total antioxidant activity (TAA), reducing power (RP), DPPH (2,2-Diphenyl-1-Picrylhydrazyl) free radical scavenging and hydrogen peroxide scavenging assays. Phytochemical screening was performed both qualitatively as well as quantitatively. Total phenolic content (TPC) and total flavonoid content (TFC) were determined through Folin- Ciocalteu reagent and aluminium chloride methods respectively. Methanol-chloroform solvent showed the presence of a high amount of TPC in milligram of gallic acid equivalent per gram of dry weight (mg of GAE/g of DW) in the extracts of all weeds. Their descending sequence was Avena fatua (74.09) ˃ Phalaris minor (65.66) ˃ Chenopodium murale (64.04) ˃ Convolvulus arvensis (61.905), while, chloroform solvent found to be best solvent for the extraction of TFC. Methanol-chloroform solvent was also found to be best solvent for TAA (Total antioxidant activity assay) which showed values in milligram of ascorbic acid equivalent per gram of dry weight (mg of AAE /g of DW), for DPPH scavenging activity, reducing power (antioxidant activity) and hydrogen peroxide scavenging activity. Phytochemical screening indicated the presence of polyphenols, flavonoids, tannins, saponins, alkaloids and glycosides in these weeds.

Analysis of pharmacoeconomic value of sitagliptin in the treatment of diabetes mellitus

OBJECTIVE

Diabetes mellitus is a chronic metabolic disease which has an adverse impact on the quality of patient's life, so patients often need to receive treatment for a long time. Selection of medications with high therapeutics effects and low cost is very important for patients to take medicine for a longer period of time. Sitagliptin is a drug which is widely used in clinics and can effectively control blood glucose level. This article explores the pharmacoeconomic value of Sitagliptin in the treatment of diabetes mellitus.

PATIENTS AND METHODS

A total of 100 patients with diabetes mellitus treated were recruited in this study. The patients were randomly divided into 4 groups with 25 cases in each group. Patients in group A were treated with pioglitazone, group B with Sitagliptin, group C with metformin and group D with glimepiride. The cost of the drugs, the treatment results and adverse effects were compared.

RESULTS

Compared with group A, C and D, the cost-effectiveness ratio of group B was low (p<0.05), and the therapeutic effect was high (p<0.05). In addition, the incidence of adverse reactions in group B was lower than that in group A, C and D (p<0.05). There was no significant difference in the levels of FPG, 2hPG and HbAlc in patients among the four groups before treatment (p>0.05). After treatment, the levels of FPG, 2hPG and HbAlc in group B were significantly lower than those in groups A, C and D (p<0.05). Finally, there was no significant difference in waist circumference and BMI among the four groups before treatment (p>0.05). After treatment, the waist circumference and BMI in group B were lower than those in groups A, C and D (p<0.05).

CONCLUSIONS

The application of Sitagliptin in the treatment of diabetic patients can effectively enhance the therapeutic effect. The cost effectiveness is satisfactory, and the blood glucose level can be maintained at a stable state.

Formulation and evaluation on human skin of a water-in-oil emulsion containing Muscat hamburg black grape seed extract

BACKGROUND

Vitis vinifera 'muscat hamburg' (Vitaceae) is a blue-black grape variety commonly found in Pakistan. It has been consumed and used in traditional medicine for centuries. Compared to other grapes, M. hamburg records one of the greatest amount of polyphenols and displays potent antioxidant activities, which make it a great candidate for its exploitation in the development of stable cream emulsions destined to improve the skin appearance.

OBJECTIVE

Evaluate the effects of stable water-in-oil (W/O) emulsion containing 2% M. hamburg grape seed extract ('formulation') on human cheek skin in comparison with the placebo ('base').

METHODS

An occlusive patch test, containing either the formulation or the base, was topically tested for 8 weeks during a winter period in young adult and healthy Pakistani male volunteers. The subjects were instructed to use twice a day the base and the formulation on their right and left cheek skin, respectively. Non-invasive measurements on these skin areas were carried out every week to assess any effects produced on melanin, elasticity and sebum. Skin compatibility assay (Burchard test) was used to report any potential skin reactivity. ANOVA, paired sample t-test and LSD test were applied to determine the statistical data significance.

RESULTS

Significant differences (P ≤ 0.05) were found between the placebo and the formulation in terms of their respective skin effects elicited on melanin, elasticity and sebum content. Nevertheless, placebo and formulation exerted similar effects on skin erythema and moisture contents. Importantly, no skin hypersensitivity cases were reported during the whole course of the study.

CONCLUSION

The developed grape-based cream could be efficiently and safely applied to improve a number of skin conditions (e.g. hyper-pigmentation, premature ageing, acne).

Formulation development of a cream containing fennel extract: in vivo evaluation for anti-aging effects

This study was aimed to formulate and evaluate anti-aging effects of a topical cream (w/o emulsion) containig extract of Fennel (Foeniculum vulgare) versus its base. Formulation containing 4% concentrated extract of Foeniculum vulgare was developed by entrapping in the inner aqueous phase of w/o emulsion and base contained no extract. Both the base and formulation were stored under different storage conditions to predict their stability. The formulation and base were evaluated for effect on skin moisture and transepidermal water loss (TEWL). The base showed insignificant while the formulation showed significant effects on skin moisture and TEWL. The parameter volume and surface evaluation of living skin (SELS) parameters SEr, SEsc, SEsm, SEw were also evaluated and showed a significant (p < or = 0.05) decline. The texture parameter energy showed a significant increase proving that the formulation possesses potential anti-aging effects.

The human metapneumovirus: a case series and review of the literature

Human metapneumovirus (hMPV) is an emerging human pulmonary pathogen that is genetically related to respiratory syncytial virus. It has been increasingly associated with respiratory illnesses over the last few decades. Immunocompromised patients are particularly susceptible with resultant morbidity and mortality. We describe our experience with 9 immunocompromised patients diagnosed with pneumonia secondary to hMPV, 2 of whom were successfully treated with aerosolized and oral ribavirin along with intravenous immunoglobulin (IVIG). We suggest that hMPV should be considered in the differential diagnosis of immunocompromised patients with acute respiratory illness. Ribavirin (oral and aerosolized) with IVIG is potentially an effective treatment option for those with severe disease.

Use of anticholinergics and the risk of cognitive impairment in an African American population

BACKGROUND

Anticholinergic properties of certain medications often go unrecognized, and are frequently used by the elderly population. Few studies have yet defined the long-term impact of these medications on the incidence of cognitive impairment.

METHODS

We report a 6-year longitudinal, observational study, evaluating 1,652 community-dwelling African American subjects over the age of 70 years who were enrolled in the Indianapolis-Ibadan Dementia Project between 2001 and 2007 and who had normal cognitive function at baseline. The exposure group included those who reported the baseline use of possible or definite anticholinergics as determined by the Anticholinergic Cognitive Burden scale. Our main outcome measure was the incidence of cognitive impairment, defined as either dementia or cognitive impairment not dementia, or poor performance on a dementia screening instrument during the follow-up period.

RESULTS

At baseline, 53% of the population used a possible anticholinergic, and 11% used a definite anticholinergic. After adjusting for age, gender, educational level, and baseline cognitive performance, the number of definite anticholinergics was associated with an increased risk of cognitive impairment (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.07-1.99; p = 0.02), whereas the number of possible anticholinergics at baseline did not increase the risk (OR 0.96, 95% CI 0.85-1.09; p = 0.55). The risk of cognitive impairment among definite anticholinergic users was increased if they were not carriers of the APOE epsilon4 allele (OR 1.77, 95% CI 1.03-3.05; p = 0.04).

CONCLUSIONS

Limiting the clinical use of definite anticholinergics may reduce the incidence of cognitive impairment among African Americans.

Pericardial effusion following esophageal variceal sclerotherapy

We report a 37-year-old man with portal cavernoma who developed pericardial effusion two weeks following sclerotherapy for esophageal varices. It responded to conservative management.

Ischemic stroke in young adults of South Asia

OBJECTIVE

To study the risk factors, etiology and management of ischemic stroke in young adults in a South Asian population.

METHODS

Retrospective study conducted at a large tertiary hospital in Karachi. One hundred and eighteen patients between fifteen and forty-five years admitted over a five year period with a diagnosis of ischemic infarct constituted the study population. The study variables included the full clinical spectrum, spanning historical, laboratory, radiological and outcome parameters.

RESULTS

Forty-three percent of patients were hypertensive and 30% were diabetic. The combination of diabetes and hypertension was found in 19.5% of patients, intra-cranial and carotid artherosclerosis in 22% and embolism in 11% of the cases. The in-hospital mortality was 11%. The outcome was excellent in 27%, good in 50% and poor in 23% of patients.

CONCLUSION

The risk factors for artherosclerosis and the contribution of intra and extra-cranial artherosclerosis were found to be much higher than those from the Western Hemisphere.

Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer

BACKGROUND

Therapeutic endoscopy has provided a new means of treating bleeding peptic ulcers. Additional medical therapy may enhance the therapeutic benefit. Hemostasis is highly pH dependent and is severely impaired at low pH. Proton pump inhibitors, by achieving a significantly higher inhibition of gastric acidity, may improve the therapeutic outcomes after endoscopic treatment of ulcers.

PATIENT AND METHODS

We enrolled 166 patients with hemorrhage from duodenal, gastric, or stomal ulcers and signs of recent hemorrhage, as confirmed by endoscopy. Twenty-six patients had ulcers with an arterial spurt, 41 patients had active ooze, 37 had a visible vessel, and 62 patients had an adherent clot. All patients received endoscopic injection sclerotherapy using 1:10,000 adrenaline and 1% polidocanol and were randomly assigned to receive omeprazole (40 mg orally) every 12 hours for 5 days or an identical-looking placebo. The outcome measures used were recurrent bleeding, surgery, blood transfusion, and hospital stay.

RESULTS

Six (7%) of 82 patients in the omeprazole group had recurrent bleeding, as compared with 18 (21%) in the placebo group (P = 0.02). Two patients in the omeprazole group and 7 patients in the placebo group needed surgery to control their bleeding (P = 0.17). One patient in the omeprazole group and 2 patients in the placebo group died (P = 0.98). Twenty-nine patients (35%) in the omeprazole group and 61 patients (73%) in the placebo group received blood transfusions (P <0.001). The average hospital stay was 4.6 +/- 1.1 days in the omeprazole group and 6.0 +/- 0.7 days in the placebo group (P <0.001).

CONCLUSION

The addition of oral omeprazole to combination injection sclerotherapy decreases the rate of recurrent bleeding, reduces the need for surgery and transfusion, and shortens the hospital stay for patients with stigmata of recent hemorrhage.

Ascaris-induced liver abscess

The prevalence, symptomatology, and outcome of Ascaris-induced liver abscess was studied prospectively in Kashmir, India, which is an endemic area of ascariasis, from December 1987 to December 1997. Of 510 patients with liver abscess admitted during this period, 74 had biliary ascariasis as the cause (14.51%). Of these 74 patients, 11 had intact ascaridae (live or dead) within the abscess. Six patients had a single abscess, and five had multiple abscesses. Seven patients had associated worms in the bile ducts. Ultrasonography was the main diagnostic procedure used. Ten patients were diagnosed based on clinical and ultrasound findings, and one was diagnosed during laparotomy. Most of the patients were young (age range 3-40 years) with a mean age of 17.20 years. Seven were females, and four were males. Ten patients underwent surgery; nine recovered completely, and one died postoperatively due to septicemia. Another patient died as well: a young child who presented late, was in refractory septic shock following suppurative cholangitis and liver abscess, and could not be taken for surgery. The mortality thus was 9.9%. Liver abscess following invasion of intrahepatic biliary radicles by ascaridae through the ampulla is an unusual complication of an otherwise common disease in Kashmir Valley, affecting children and young adults. The outcome depends on early diagnosis and surgical drainage of the abscess with extraction of worms from the ducts.

Cellular radiosensitivity of patients with papillary thyroid cancer

Cultured skin fibroblasts from patients with papillary (differentiated) thyroid carcinomas were compared to those from healthy subjects, ataxia telangiectasia (AT) homozygotes and AT heterozygotes for colony-forming ability after low dose-rate irradiation, and post-irradiation DNA synthesis as indicated by uptake of [3H]-thymidine. The cells from the cancer patients exhibited enhanced radiosensitivity (intermediate between normal and AT) and less than normal level of radioinduced inhibition of DNA synthesis.

Bone mineral density of the spine and femur in healthy Saudi females: relation to vitamin D status, pregnancy, and lactation

Bone mineral density (BMD) measurements of the anterio-posterior lumbar spine and the proximal femur using dual-energy x-ray absorptiometry, as well as relevant clinical and biochemical parameters, were determined in 321 healthy Saudi females in order to establish reference values and to study the effects of physical and lifestyle factors on BMD. Mean +/- SD of age, body mass index (BMI), number of pregnancies, and total duration of lactation were 35.4 +/- 11.3 years, 26.5 +/- 5.2 kg/m2, 3.1 +/- 3.1, and 23.7 +/- 42.4 months, respectively. Mean +/- SD of serum calcium, 25-hydroxyvitamin D (25OHD), and PTH levels were 2.37 +/- 0.09 mmol/liter, 24.5 +/- 17.2 nmol/liter, and 52.0 +/- 30.8 pg/ml, respectively. Peak BMD values were observed around age 35 years at the spine and earlier at the femur. Compared with USA females, Saudi females had lower weight-matched Z scores at the spine (-0.126 +/- 1. 078, P = 0.04), femoral neck (-0.234 +/- 0.846, P < 0.0001), and Ward's triangle (-0.269 +/- 1.015, P < 0.0001). Further, the prevalence of osteopenia and osteoporosis in subjects >/=31 years old were 18-41% and 0-7%, respectively, depending on the site examined. Severe hypovitaminosis D (25OHD level </=20 nmol/liter) was present in 52% of the subjects. However, there was no correlation between 25OHD level and BMD at any site. Parathyroid hormone (PTH) levels correlated significantly with 25OHD levels (r = -0.28, P < 0.0001) and with weight-matched BMD Z scores at the spine (r = -0.17, P = 0.005), femoral neck (r = -0.16, P = 0.007), and Ward's triangle (r = -0.2, P = 0.0008), suggesting that the distribution of 25OHD levels in the cohort is below the threshold needed for maintaining normal BMD. On the other hand, number of pregnancies and total duration of lactation correlated with weight-matched BMD Z scores at the spine (r = -0.17, P = 0.003; r = -0.1, P = 0.08, respectively). We conclude that BMD in healthy Saudi females is significantly lower than in their USA counterparts. This may be due in part to increased number of pregnancies and longer duration of lactation together with prevalent vitamin D deficiency. http://link.springer-ny.com/link/service/journals/00223/bibs /65n1p23. html

Carotid Doppler ultrasonography in young stroke patients

BACKGROUND

The present study focuses on the role of carotid doppler ultrasonography (CDUS) in the diagnosis and management of carotid stenosis in young stroke patients.

METHODS

The findings of carotid doppler in 45 ischemic stroke patients between 15-45 years of age were reviewed retrospectively. The variables of interest for this study included risk factors for atherosclerotic disease, primary abnormality detected on carotid doppler ultrasonography (ulceration vs. stenosis), degree of stenosis and the type of plaque (soft vs. calcified).

RESULTS

The prevalence of hypertension and diabetes was 50% and 35% respectively. The rate of carotid stenosis in the study population was found to be 31%. The degree of stenosis was mild in 35% and moderate in 21%. High-grade stenosis was found in 21% of patients. The plaque was soft in the majority of cases (43%).

CONCLUSION

The proportion of carotid stenosis in young stroke patients was relatively high compared with previous studies. This may be due to an increase in the risk factors for atherosclerotic disease in developing countries.

CT and MR imaging in young stroke patients

BACKGROUND

This study investigates the role of CT and MR imaging in the diagnosis and management of young stroke patients.

METHODS

CT scan findings of 108 patients and MR findings of 30 patients between 15-45 years of age were reviewed retrospectively. The variables included the territory of infarct on CT and MR imaging, the cortical distribution and size of infarct.

RESULTS

About 80% of the patients had infarcts of the carotid territory and 20% the vertebro-basilar distribution. More than half of the infarcts were cortical (56%). The yield of MR imaging was much higher for deeper structures such as basal ganglia, thalamus and brainstem. In half the cases, the infarct size was more than 3 cm.

CONCLUSION

The ratio of carotid to vertebro-basilar infarcts was similar to that reported previously. A large proportion of the carotid territory infarcts were cortical. Deeper infarcts were better imaged with MR scan. There was a high proportion of large infarcts.

Sequential serum hepatitis C viral RNA levels longitudinally assessed by branched DNA signal amplification

The aim of this study was to determine the stability of viral load over an extended period in patients with chronic hepatitis C virus (HCV). Sequential serum specimens collected from fourteen non-alcoholic adult patients with chronic HCV between 1990 and 1997 were tested retrospectively for HCV RNA levels by branched DNA assay (Quantiplex HCV RNA 2.0 [Chiron Diagnostics, Emeryville, CA]). A minimum of three serum samples was obtained at various intervals from each patient. None of the patients received antiviral therapy. Liver biopsies, available for 10 of 14 patients, showed mild or moderate hepatitis in seven and cirrhosis in three (one developed cirrhosis during follow-up). RIBA strip immunoassay showed that 7, 3, and 4 patients had viral genotypes 1, 2, and 3, respectively. The follow-up time averaged 5.3 years (range, 3.7 to 6.6 years). Eight patients (57.2%) showed increased viral levels from baseline to follow-up, the remaining six patients (42.8%) showed decreased viral levels. The three cirrhotic patients had the highest viral levels over time. The mean change was a 0.29-fold decrease (median, +1.14 [corrected]; range, -17.49 to +7.32). A less than twofold change in either direction was demonstrated for six patients (42.8%), and a less than threefold change was demonstrated for 10 patients (71.4%). Variation from baseline to last follow-up as calculated by log determination showed that the viremic load varied less than one log10 in all but one individual. These results show that viral load remains relatively stable over prolonged periods in most untreated patients with chronic hepatitis C.

Short-course ceftriaxone therapy in spontaneous bacterial peritonitis

Forty patients with spontaneous bacterial peritonitis, three of whom had complicating acute hepatitis syndrome, eight late-onset hepatic failure, and 29 with cirrhosis, were treated with ceftriaxone 2 g intravenously once daily for 5 days. Ascitic fluid culture was positive in 28 patients, with Escherichia coli and Klebsiella as common isolates. All the bacteria isolated were sensitive to ceftriaxone except Enterococcus faecalis, which was isolated in a cirrhotic patient. All culture-positive patients sensitive to ceftriaxone showed bacteriological cure and 26 (65%) patients showed cytological cure after 48 hours of treatment. A total of 95% were cured of their infection after 5 days of treatment. Twelve (30%) patients died during hospitalisation after documented cure of their spontaneous bacterial peritonitis (renal failure, gastrointestinal bleed and cerebral oedema were the primary causes of death). Infection-related mortality due to Pseudomonas septicaemia was seen in one cirrhotic patient.

Outcome of in-hospital pediatric cardiac arrest

BACKGROUND

The outcome of pediatric cardiac arrest is poor, and attempts to improve it have not been very successful. The aim of this study was to analyze the outcome of a large number of in-hospital pediatric cardiac arrest patients, and to determine the factors that influence this outcome.

PATIENTS AND METHODS

The records of hospital inpatients at King Faisal Specialist Hospital and Research Centre who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. Success of resuscitation was analyzed as: 1) short-term (restoration of spontaneous circulation); and 2) long-term (discharge from hospital).

RESULTS

Of 234 such patients, 171 (73.1%) survived the initial resuscitation, and 66 (28.2%) were discharged from hospital. Success of outcome was not related to age, time of day, or location of arrest. Longer resuscitation time was associated with less chance of restoration of spontaneous circulation (P<0.001), and lower hospital discharge rate. RESULTS for patients with congenital heart disease were similar to those with other medical or surgical conditions. Restoration of spontaneous circulation from asystole was more difficult when compared to other arrest rhythm, but once circulation was restored, long-term outcome was not influenced by rhythm.

CONCLUSION

Asystole and longer resuscitation time are associated with poorer outcome, however, successful restoration of spontaneous circulation with long-term survival can be achieved after prolonged resuscitation.

Percutaneous drainage compared with surgery for hepatic hydatid cysts

BACKGROUND

In recent years percutaneous drainage has been used successfully to treat the hepatic hydatid cysts of echinococcal disease. We performed a controlled trial to compare the safety and efficacy of percutaneous drainage with those of surgical cystectomy, the traditional treatment.

METHODS

In a prospective study, we randomly assigned 50 patients with hepatic hydatidosis to treatment with percutaneous drainage (25 patients) or cystectomy (25). Albendazole (10 mg per kilogram of body weight per day for eight weeks) was administered to the patients who underwent percutaneous drainage. Serial assessments included clinical and biochemical examinations, ultrasonography, and serologic tests of echinococcal-antibody titers.

RESULTS

The mean (+/-SD) hospital stay was 4.2+/-1.5 days in the drainage group and 12.7+/-6.5 days in the surgery group (P<0.001). Over a mean follow-up period of 17 months, the mean cyst diameter decreased from 8.0+/-3.0 to 1.4+/-3.5 cm (P<0.001) after percutaneous drainage and from 9.1+/-3.0 to 0.9+/-1.8 cm (P<0.001) after surgery. The final cyst diameter did not differ significantly between the two groups (P=0.20). The cysts disappeared in 22 patients (88 percent) in the drainage group and in 18 (72 percent) in the surgery group (P=0.29). After an initial rise, the echinococcal-antibody titers fell progressively and at the last follow-up were negative (<1:160) in 19 patients (76 percent) in the drainage group and 17 (68 percent) in the surgery group (P=0.74). There were procedure-related complications in 8 patients (32 percent) in the drainage group and 21 (84 percent) in the surgery group, 17 of whom had fever postoperatively (P<0.001).

CONCLUSIONS

Percutaneous drainage, combined with albendazole therapy, is an effective and safe alternative to surgery for the treatment of uncomplicated hydatid cysts of the liver and requires a shorter hospital stay.

A comparison of omeprazole and placebo for bleeding peptic ulcer

BACKGROUND

The role of medical treatment for patients with bleeding peptic ulcers is uncertain.

METHODS

We conducted a double-blind, placebo-controlled trial in 220 patients with duodenal, gastric, or stomal ulcers and signs of recent bleeding, as confirmed by endoscopy. In 26 patients the ulcers showed arterial spurting, in 34 there was active oozing, in 35 there were nonbleeding, visible vessels, and in 125 there were adherent clots. The patients were randomly assigned to receive omeprazole (40 mg given orally every 12 hours for five days) or placebo. The outcome measures studied were further bleeding, surgery, and death.

RESULTS

Twelve of the 110 patients treated with omeprazole (10.9 percent) had continued bleeding or further bleeding, as compared with 40 of the 110 patients who received placebo (36.4 percent) (P<0.001). Eight patients in the omeprazole group and 26 in the placebo group required surgery to control their bleeding (P<0.001). Two patients in the omeprazole group and six in the placebo group died. Thirty-two patients in the omeprazole group (29.1 percent) and 78 in the placebo group (70.9 percent) received transfusions (P<0.001). A subgroup analysis showed that omeprazole was associated with significant reductions in recurrent bleeding and surgery in patients with nonbleeding, visible vessels or adherent clots, but not in those with arterial spurting or oozing.

CONCLUSIONS

In patients with bleeding peptic ulcers and signs of recent bleeding, treatment with omeprazole decreases the rate of further bleeding and the need for surgery.

A prospective study of VEC-POB and POCE chemotherapy in aggressive non-Hodgkin's lymphoma

The optimal combination and scheduling of chemotherapy for aggressive non-Hodgkin's lymphoma is unclear, and the elderly have a poor tolerance to treatment. A Phase II prospective study was undertaken using outpatient weekly combination chemotherapy: the VEC-POB (etoposide, epirubicin, cyclophosphamide, cisplatin, Oncovin, bleomycin, and prednisone) regimen in patients < 60 years and less intensive POCE (etoposide, Oncovin, cyclophosphamide, and epirubicin) in patients > or = 60 years. All patients with intermediate and high-grade lymphoma (International Working Formulation) with bulky disease and/or advanced stages (III, IV) seen between January 1991 and June 1992 were entered. Of 29 patients treated with VEC-POB, 23 patients (79%) achieved complete remission (CR), with one (3%) toxic death. Overall survival at 29 months is 67%, and disease-free survival at 60 months is 60%. Of 29 patients treated with POCE, 14 achieved CR, with three (10%) toxic deaths. Overall survival is 58% at 18 months, and disease-free survival at 10 months is 50%. Adverse prognostic factors were analyzed. The results are comparable to the best results achieved with other regimens, and toxicity is acceptable.

Anti-oxidant effects of curry leaf, Murraya koenigii and mustard seeds, Brassica juncea in rats fed with high fat diet

Status of lipid peroxidation was studied in rats induced high fat diet and some commonly used spices, viz. Murraya koenigit and Brassica juncea. The study revealed that these species alter the peroxidation (thiobarbituric acid reactive substances) level to a beneficial extent. Histological studies also focus on modulation of hepatic functions to near normal level.

Biochemical response in rats to the addition of curry leaf (Murraya koenigii) and mustard seeds (Brassica juncea) to the diet

Three groups with 12 weanling male albino rats were group fed for 90 days on a standard laboratory rat diet plus 20% coconut oil either without a supplement or with the addition of 10% curry leaf or 10% mustard seeds. Feed was offered at a level of 10% body weight. At the end of the trial, measurements were made on the total serum cholesterol, high density lipoproteins, low density lipoproteins, and very low density lipoproteins fractions, release of lipoproteins into the circulation, lecithin cholesterol acyl transferase activity and lipoprotein lipase activity. Feed intake and mean body weight of the rats on each treatment was not significantly different. Both spices resulted in a reduction in total serum cholesterol and LDL + VLDL, an increase in the HDL, lower release of lipoproteins into the circulation and an increase in the LCAT activity.

Role of Murraya koenigii (curry leaf) and Brassica juncea (Mustard) in lipid peroxidation

The status of lipid peroxidation was investigated in rats fed M. Koenigii (curry leaf) and B. juncea (Mustard). Concentration of malondialdehyde showed a significant decrease, while hydroperoxides and conjugated dienes were significantly increased in liver and heart of both the experimental groups. SOD and catalase activity was found to be increased in liver and heart of both the spices administered groups. Glutathione levels in liver, heart and kidney were lowered in rats administered these spices. Glutathione reductase, glutathione peroxidase and glutathione S-transferase activity showed a sharp increase in the experimental groups compared to the controls.

Murraya koenigii and Brassica juncea--alterations on lipid profile in 1-2 dimethyl hydrazine induced colon carcinogenesis

The influence of the two commonly used spices Murraya koenigii (curry leaf) leaf and Brassica juncea (mustard) seeds on the levels of lipids, fecal bile acids and neutral sterols was studied in rats administered 1,2-dimethyl hydrazine (1,2 DMH). The levels of cholesterol and phospholipids decreased in the experimental groups when compared with the control. The cholesterol phospholipid ratio showed an elevated level in the DMH treated control compared with the species group. Bile acids and neutral sterols showed a sharp increase in the spices treated groups in liver and feces when compared with the control. Morphological and histological studies revealed that the mean number of neoplasms in the colon and intestine were significantly low in the spices fed groups.

Haematological & histological studies after curry leaf (Murraya koenigii) & mustard (Brassica juncea) feeding in rats

Whole curry leaf and mustard fed to rats at doses equal to normal human intake did not cause any adverse effect on food efficiency ratio (FER), red blood cell count (RBC), white blood cells (WBC), total count, differential counts or on the levels of blood constituents, like serum electrolytes, blood urea, haemoglobin, total serum protein, albumin-globulin ratio, fibrin level, glycosylated haemoglobin and the activity of glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT) and alkaline phosphatase in serum. No histopathological changes were observed in the liver of rats administered curry leaf and mustard.

Elevated serum creatinine level in thyroid cancer patients undergoing withdrawal of thyroxine therapy for radioiodine scan/treatment

Chronic hypothyroidism is known to cause a significant reversible decrease in glomerular filtration rate (GFR). However, the effect on GFR of acute hypothyroidism, routinely induced in thyroid cancer patients in preparation for radioiodine scan/treatment, is not known. We studied the prevalence of abnormal serum creatinine level and the degree of its increase in hypothyroid patients with thyroid cancer four weeks after the withdrawal of thyroxine therapy. Creatinine level was measured in 116 patients on 191 hypothyroid episodes and in 56/116 and 18/116 patients while euthyroid or mildly hyperthyroid respectively. Abnormal creatinine level was significantly more prevalent in the hypothyroid state (34.5% vs 4% in the euthyroid or mildly hyperthyroid states) and significantly more common in males (50% vs 29% in females), in patients </=31 years old (48% vs 26% in older patients) and in patients with a TSH level >150 mU/L (55% vs 30% with TSH </=150 mU/L). Analyzing data on females only or including all hypothyroid episodes did not significantly alter the results. Further, compared to patients with normal creatinine level, patients with abnormal creatinine levels were significantly younger (in the whole group, mean age 35.1 vs 42.5 years; in the subgroup of patients with a TSH level > 150 mU/L, 29.8 vs 41.4 years; in females, 28.3 vs 42.5 years) and there was a significant negative association between the presence of abnormal creatinine levels and different age groups. Compared to levels obtained in the euthyroid or mild hyperthyroid states, creatinine levels increased in the hypothyroid state on average 32% (23microM/L, P=0.0001) with 24% of patients having >/=50% increase. Elevated serum creatinine levels are rather common in thyroid cancer patients undergoing temporary withdrawal of thyroxine treatment and more so in males, younger patients or in association with higher TSH levels. Since the clearance of iodine is linearly related to GFR, our study suggests that in the setting of hypothyroidism, the bioavailability of a given dose of radioiodine may have significant individual variation.

Antibodies to carbonic anhydrase in patients with immune cholangiopathies

BACKGROUND/AIMS

Bile duct epithelia contain an abundance of carbonic anhydrase. Antibodies to this enzyme have been described in autoimmune disorders. Serum from patients with immune-mediated liver diseases was studied to determine whether antibodies to carbonic anhydrase II and/or pyruvate dehydrogenase could distinguish autoimmune cholangitis as immunologically distinct from primary biliary cirrhosis.

METHODS

Antibody assays to carbonic anhydrase II (Western blot) and pyruvate dehydrogenase (flow cytometry) were performed on the sera of patients with autoimmune cholangitis (6), primary biliary cirrhosis (12), primary sclerosing cholangitis (12), autoimmune hepatitis (12), and control (Gilbert syndrome; 8).

RESULTS

Reactivity to carbonic anhydrase II was detected in 5 of 6 patients with autoimmune cholangitis, 1 of 12 patients with primary biliary cirrhosis, 1 of 12 patients with autoimmune hepatitis, and no other patients. Individuals with autoimmune cholangitis were more likely than the other patients to be reactive to carbonic anhydrase II (P < 0.001). Patients with primary biliary cirrhosis were more reactive to pyruvate dehydrogenase compared with all other groups (P < 0.001).

CONCLUSIONS

An antibody to human carbonic anhydrase II is frequently detected in the sera of patients with autoimmune cholangitis and is uncommon or not present in other cholangiopathies. These data provide evidence that autoimmune cholangitis and primary biliary cirrhosis represent distinct entities with unique patterns of immunoreactivity.

Hypoglycemic action of Murraya koenigii (curry leaf) and Brassica juncea (mustard): mechanism of action

Effect of Murraya koenigii and Brassica juncea on carbohydrate metabolism has been studied using rats as experimental animals. Both showed significant hypoglycemic action. There was increase in the concentration of hepatic glycogen and glycogenesis, as evident from the increased activity of glycogen synthetase, and decrease in glycogenolysis and gluconeogenesis as evident from the decreased activity of glycogen phosphorylase and gluconeogenic enzymes.

Post-irradiation DNA synthesis inhibition and G2 phase delay in radiosensitive body cells from non-Hodgkin's lymphoma patients: an indication of cell cycle defects

In the present study, both post-irradiation DNA synthesis and G2 phase accumulation were analyzed in lymphoblastoid cell lines (LCLs) and fibroblast cell strains derived from (Saudi) patients with non-Hodgkin's lymphoma (NHL), ataxia telangiectasia (AT), AT heterozygotes and normal subjects. A comparison of the percent DNA synthesis inhibition (assayed by 3H-thymidine uptake 30 min after irradiation), and a 24 h post-irradiation G2 phase accumulation determined by flow cytometry placed the AT heterozygotes and the NHL patients in an intermediate position between the normal subjects (with maximum DNA synthesis inhibition and minimum G2 phase accumulation) and the AT homozygotes (with minimum DNA synthesis inhibition and maximum G2 accumulation). The similarity between AT heterozygotes and the NHL patients with respect to the two parameters studied after irradiation was statistically significant. The data indicating a moderate abnormality in the control of cell cycle progression after irradiation in the LCLs and fibroblasts from NHL patients may explain the enhanced cellular and chromosomal radiosensitivity in these patients reported by us earlier. In addition to demonstrating a link between cell cycle abnormality and radiosensitivity as a possible basis for cancer susceptibility, particularly in the NHL patients, the present studies emphasized the usefulness of the assay for 24 h post-irradiation G2 phase accumulation developed by Lavin et al. (1992) in characterizing AT heterozygote-like cell cycle anomaly in cancer patients irrespective of whether they carried the AT gene or any other affecting the cell cycle.

Increased radiosensitivity and radioresistant DNA synthesis in cultured fibroblasts from patients with coronary atherosclerosis

Cultured skin fibroblasts from five patients with atherosclerosis who underwent coronary artery bypass graft surgery were compared with those from one ataxia telangiectasia (AT) homozygote, three AT heterozygotes, and five healthy subjects to determine their sensitivity to gamma radiation as determined by a colony survival assay. Fibroblasts from four of these patients were also compared with those from two AT homozygotes, two AT heterozygotes, and three healthy subjects to determine postirradiation [3H]thymidine incorporation, indicating the levels of radioresistant DNA synthesis (RDS). On the basis of colony survival assay, after long-term irradiation (at low dose rate, ie, 0.007 Gy/min), fibroblasts from all five patients with atherosclerosis exhibited radiosensitivity that was intermediate between that of the healthy subjects and that of patients with the known radiosensitive syndrome AT. However, there was a considerable interstrain difference in the radiosensitivity of fibroblasts from patients with atherosclerosis, with their mean D10 values (radiation dose resulting in 10% cell survival) varying between 2.3 and 6.2 Gy, whereas the mean D10 values for the cells from the AT homozygote, AT heterozygotes, and healthy subjects were 2.0, 3.8, and 9.0 Gy, respectively. One of the patients with atherosclerosis showed cellular radiosensitivity quite similar to that of the AT homozygote, up to 2% to 10% of survival levels after short- (at a dose rate of 8 Gy/min) and long-term irradiation, respectively. The results of [3H]thymidine incorporation showed an AT heterozygote-like RDS in fibroblasts from patients with atherosclerosis that appeared to be intermediate between that of AT homozygotes and that of healthy subjects, suggesting a partial deregulation of cell cycle in the patients with atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Spectrum of hepatitis E virus infection in India

A solid phase enzyme linked immunosorbent assay (ELISA) that detects IgM and IgG to hepatitis E virus (HEV) was used to study seroepidemiology in 40 healthy subjects and 227 consecutive patients with liver diseases in an endemic area. Fifty-two of the liver diseases patients (22.9 percent) had acute hepatitis E. In contrast, none of the 40 healthy subjects were positive for IgM anti-HEV, validating the ELISA assay. Twenty-three of 25 (92%) patients with epidemic non-A, non-B hepatitis were confirmed as having acute hepatitis E. Only 1 of the 10 patients with sporadic, fulminant hepatic failure of non-A, non-B, non-C etiology was positive for IgM anti-HEV. Five (31.2%) of the 16 patients with acute hepatitis in HBsAg carriers were positive for IgM anti-HEV. One patient with acute hepatitis B was coinfected with acute hepatitis E. Acute hepatitis was a disease of the adult population, with peak attack rates in the second and third decades of life. This disease was seen in only 4 (16%) of the 25 patients with acute viral hepatitis occurring below 14 years of age. Cholestasis was predominant in 25% of patients, enzyme elevation was monophasic, and all patients had clinical and biochemical recovery from the disease. The data suggest that the majority of patients with acute sporadic non-A, non-B, non-C hepatitis in India have hepatitis E. However, fulminant hepatic failure to sporadic nature is rarely from hepatitis E.

Malignant cystosarcoma phyllodes: A review of the clinical experience at King Faisal Specialist Hospital and Research Centre

Twelve females with cystosarcoma phyllodes of the breast were referred to King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1980 and 1990, representing 0.8% of breast cancer patients seen during this period. Median age was 45 years (range 16 to 65 years). Seven patients (58%) were premenopausal. All patients presented with breast mass, which measured >10 cm in 58% of them. The median duration of symptoms was 15 months (range two to 174). Neither axillary lymph nodes nor distant metastases were seen at presentation. Surgery was the cornerstone of primary treatment (wide local excision in three and mastectomy in nine). Two patients received adjuvant chemotherapy and locoregional irradiation. All patients had malignant tumors histologically. Of the four tumors assayed for hormonal receptors, one was positive for estrogen and progesterone receptors. At a median follow-up of 17 months (range two to 77), four patients had relapsed; one died at 19 months and the projected five year survival is 83%. This limited data supports the observation that malignant cystosarcoma phyllodes is a distinctive clinicopathological entity of female breast cancer with a different natural history from carcinoma of the breast. Our survival results are similar to reported experience from the literature.

Worm extraction and biliary drainage in hepatobiliary and pancreatic ascariasis

From December 1989 to March 1992, 50 (32%) of 156 patients with hepatobiliary and pancreatic ascariasis underwent various endoscopic interventional procedures. Endoscopic intervention was performed when patients did not respond to energetic symptomatic treatment within the first few days of hospitalization (n = 45) or when worms had not moved out of the ducts into the duodenum at 3 weeks (n = 5). Worm extraction was successful in all 18 patients from the ampullary orifice and in 34 (89.5%) of 38 patients from the bile or pancreatic duct. In five patients with pyogenic cholangitis, endoscopic nasobiliary drainage was performed to decompress the bile ducts. After worm extraction/nasobiliary drainage, 41 (91%) of the 45 patients with biliary disease (n = 42) or acute pancreatitis (n = 3) had rapid relief of symptoms. Three patients developed complications related to endoscopy, including cholangitis (n = 2) and hypotension (n = 1).

Serial cholangiographic appearances in recurrent pyogenic cholangitis

From December 1982 to December 1991, cholangiograms were obtained in 227 patients with recurrent pyogenic cholangitis. Cholangiographic abnormalities included biliary dilation, calculi, sludge, excessive branching, and arrowhead formation of intrahepatic ducts and biliary strictures. In 21 patients, previous evidence of biliary ascariasis was seen. Repeat cholangiograms were performed in 55 patients in a follow-up period of 18.0 +/- 1 months. Of these patients, 12 treated conservatively continued to get recurrent cholangitis and revealed worsening abnormalities on repeat cholangiograms. Another 25 patients had successful endoscopic sphincterotomy and extraction of biliary calculi. These patients remained free of symptoms on follow-up, with significant resolution of abnormalities on repeat cholangiograms. The remaining 18 patients with failed surgical or endoscopic interventions continued to get recurrent episodes of cholangitis and worsening of abnormalities on repeat cholangiograms. This retrospective study indicates that the natural course of recurrent pyogenic cholangitis is a progressive, destructive cholangiopathy. Ascaris lumbricoides invasion of the biliary tree is an initiating event in a sub-group of patients.

Biliary abnormalities associated with extrahepatic portal venous obstruction

We prospectively studied 21 consecutive patients with extrahepatic portal venous obstruction for evidence of biliary tract disease. Two patients were first seen with extrahepatic cholestasis; another had recurrent cholangitis. All three patients with clinically manifest biliary disease were adults. Another five patients had icterus on clinical examination. Liver function tests revealed elevated bilirubin levels in 14 patients (66.6%), elevated alkaline phosphatase levels in 17 (80.9%) and elevated serum ALT levels in 8 (38.0%). Endoscopic retrograde cholangiography revealed abnormal findings in 17 patients (80.9%). The changes involved the common bile duct (66.6%) more often than they did the hepatic bile ducts (38.1%). Cholangiographic abnormalities included strictures (52.4%), caliber irregularity (23.8%), segmental upstream dilatation (42.8%), ectasia (9.5%), collateral veins causing extraluminal bile duct impressions (14.3%), displacement of ducts (9.5%), angulation of ducts (4.7%) and pruning of intrahepatic ducts (9.5%). The pathogenesis of such cholangiographic abnormalities is unknown. However, possible factors in such changes include collateral veins bridging the blocked portal vein, causing bile duct impressions; fibrous scarring of porta hepatis, causing angulation of bile duct; and ischemic injury to bile duct, leading to stricture formation and caliber irregularity. Biliary disease is important in the clinical outcome of patients with extrahepatic portal venous obstruction because variceal sclerotherapy has prolonged the life expectancies of such patients.

Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: a prospective, randomized study

BACKGROUND

Recently, drug treatment and percutaneous drainage have been used successfully when treating hepatic hydatid cysts. Until now, there is no published study comparing the relative safety and efficacy of these two forms of treatment.

METHODS

In a prospective study, 33 hepatic hydatid cysts were randomly distributed to receive percutaneous drainage (10), albendazole (10 mg.kg-1.day-1 for 8 weeks) plus percutaneous drainage (12), and albendazole alone (11). Patients were serially assessed by clinical and biochemical examinations, ultrasonography, and hydatid serology.

RESULTS

On serial ultrasonography, cysts attained heterogeneous echopattern in 18, uniform echogenicity in 11, and disappearance in 3. All 22 cysts treated with percutaneous drainage and only 2 (18.2%) cysts treated with albendazole alone reduced in size and change in echopattern (P < 0.01). Maximum size reduction was observed in cysts treated with a combination of percutaneous drainage and albendazole (P < 0.05). Complications observed with drainage were cyst infection in 2 patients, fever in 3, cyst biliary rupture in 1, and urticaria in 2. These were managed successfully without any mortality. Three patients who received albendazole developed reversible elevation of liver cell enzymes.

CONCLUSIONS

It was concluded that percutaneous drainage with albendazole therapy is an effective form of management for hepatic hydatid cysts.

Hepatitis C virus antibodies in acute and chronic liver disease in India

The prevalence of serum antibodies to hepatitis C virus was assessed by an enzyme-linked immunosorbent assay in patients with epidemic non-A, non-B hepatitis (14), sporadic non-A, non-B hepatitis (42), chronic hepatitis (14) and cirrhosis (26). None of the patients with epidemic non-A, non-B hepatitis (14) and acute self-limiting sporadic non-A, non-B hepatitis without prior parenteral exposure (38) tested positive for hepatitis C virus antibody. Based on epidemiologic features, hepatitis E virus is presumably the etiologic agent for both these entities. Hepatitis C virus (HCV) antibody was positive in none of the patients with cryptogenic chronic hepatitis (11) and in 2(8%) patients with cryptogenic cirrhosis (25). It was concluded that cryptogenic chronic hepatitis and cirrhosis in India may be caused by alternative viral agents of the non-A, non-B type or by hepatotoxins to which the population may be exposed. Of 8 patients with prior parenteral exposure (transfusions 6, needle pricks 2) 5 (62.5%) patients tested positive for HCV antibody. HCV antibody was detected in 1 (25%) patient with acute self-limiting, parenterally transmitted non-A, non-B hepatitis and in 4 (100%) patients with chronic parenterally transmitted non-A, non-B hepatitis.