Stereotactic Radiosurgery as an Effective and Safe Treatment Modality in Central Nervous System Lymphoma, a Single Institution Experience

PURPOSE/OBJECTIVE(S)

CNS lymphoma (CNSL) is an aggressive liquid cancer with the potential for rapid progression. Standard treatment regimens for CNSL have included chemotherapy and whole brain radiotherapy (WBRT). WBRT carries a high risk of leukoencephalopathy (LE) manifesting as cognitive decline and is identifiable on brain MRI as fluid attenuation inversion recovery (FLAIR) changes. Stereotactic radiosurgery (SRS) can precisely deliver higher biologically effective doses of radiation, while minimizing damage to surrounding healthy brain tissue. SRS offers enhanced local control in CNSL with minimal risk of LE.

MATERIALS/METHODS

Patients undergoing SRS at an NCI-designated comprehensive cancer center from 2000 to 2022 were prospectively enrolled into a database. Twenty-nine consecutive patients diagnosed with relapsed primary CNSL (59%) or secondary CNSL (41%) were included in this study. Median age at diagnosis was 70 (range 23-91) years and 14 were female. Follow up MRI imaging was obtained at 1-, 3-, 6- and 12-months post-procedure. Measurement of tumor volumes was performed at treatment and each subsequent follow-up by image co-registration and tumor segmentation. Pre and post SRS brain MRIs were independently reviewed by a neuro-radiologist to score the grade of LE for each patient. Progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan-Meier analyses and Log-rank tests using statistical software.

RESULTS

Twenty-nine patients treated for 50 tumors were studied. Twenty-four patients were treated for a single tumor, and 5 for multiple tumors. Six patients underwent repeat SRS treatment for 10 out-of-field recurrences and 1 patient for an in-field recurrence. Of the 35 SRS procedures performed, 32 (88%) were single session delivery and 3 were hypofractionated. Stereotactic immobilization was achieved with frame (57%) or thermoplastic mask (43%). Median prescribed dose was 14 Gy (range 10-21) to the 50% isodose line (range 40-100). Median coverage, selectivity and gradient index were 0.97, 0.69, and 2.9 respectively. Median follow-up time was 4.5 months (range 0.5-64). Twenty-six (52%) tumors completely responded to treatment with no residual enhancement, while the rest decreased in volume. No tumor failed to respond to treatment. Median time to best volumetric response was achieved in 2.9 months (range 1-6.1) and median volume of best response was zero cc (range 0-1.19). The median OS of the cohort was 7.0 months (95% CI 5.1-8.9), while the median PFS was 5.0 months (95% CI 1.2-8.8). Median score of LE was zero, and only one patient experienced grade 3 MRI FLAIR changes.

CONCLUSION

With a median time to response of 2.9 months, a 100% initial response rate and a single in-field failure, our analysis demonstrates a rapid and effective response of CNSL to SRS. Distant failures were controlled with repeat SRS. The absence of LE in the treated patients provides further evidence for safety and tolerability of SRS in CNSL.

Epidemiology, pathogenesis, diagnosis, surveillance, and management of hepatocellular carcinoma associated with vascular liver disease

Vascular liver disease (VLD) presents special challenges in the diagnosis, surveillance, and treatment of hepatocellular carcinoma (HCC). HCC arising in the setting of vascular liver disease is often thought to be due to elevated hepatic arterial blood flow, rather than progressive fibrosis from chronic inflammation as with other chronic liver conditions such as viral hepatitis, autoimmune, and metabolic liver diseases. Vascular alteration inherent in VLD often impedes HCC non-invasive diagnosis and loco-regional treatment that depend on vascular properties found in typical liver environment. Benign and pre-malignant liver nodules such as focal nodular hyperplasia and hepatocellular adenoma are also more common in certain VLDs, further adding to surveillance and diagnostic challenges. In this synopsis, we aimed to review available literature on the epidemiology, surveillance, diagnosis, and management of HCC in patients with VLD and specifically Budd-Chiari syndrome, congenital porto-systemic shunts, Fontan-associated liver disease, hereditary hemorrhagic telangiectasia.

Compositional cyber-physical epidemiology of COVID-19

The COVID-19 pandemic has posed significant challenges globally. Countries have adopted different strategies with varying degrees of success. Epidemiologists are studying the impact of government actions using scenario analysis. However, the interactions between the government policy and the disease dynamics are not formally captured. We, for the first time, formally study the interaction between the disease dynamics, which is modelled as a physical process, and the government policy, which is modelled as the adjoining controller. Our approach enables compositionality, where either the plant or the controller could be replaced by an alternative model. Our work is inspired by the engineering approach for the design of Cyber-Physical Systems. Consequently, we term the new framework Compositional Cyber-Physical Epidemiology. We created different classes of controllers and applied these to control the disease in New Zealand and Italy. Our controllers closely follow government decisions based on their published data. We not only reproduce the pandemic progression faithfully in New Zealand and Italy but also show the tradeoffs produced by differing control actions.

Real-world experience of regorafenib in patients with hepatocellular carcinoma: A multicenter United Kingdom study

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Background: Regorafenib was the first treatment to demonstrate a survival benefit in patients with HCC after progression on sorafenib. The RESORCE trial found that regorafenib improved overall survival with acceptable toxicity, in patients with disease progression on sorafenib who tolerated ≥400mg sorafenib daily and had Child-Pugh A liver function. Methods: We performed a multicentre, retrospective, observational study of patients with HCC receiving regorafenib in the UK, following its availability in April 2018. Results: Data on a total of 104 patients were included from April 2018–August 2019, and 80.8% were male. Age was collected in 85 patients, with a median of 68 years (range 22–86). 23.5% had NAFLD, 21.2% had ALD, 12.9% had HBV, and 3.5% had HCV. Prior management included sorafenib (100%), TACE (30.8%), resection (12.9%). Duration of sorafenib treatment was evaluable in 99/104 patients, and reported a median of 8.7 months (range 1.8–76.6). Duration of regorafenib treatment was evaluable in 92/104 patients, and reported a median of 3.9 months (range 0.0–15.7). Following treatment with regorafenib, 6 patients (5.8%) achieved partial response, 37 (35.6%) achieved stable disease and 45 (43.3%) had progressive disease as the best response. 15 (14.4%) were not assessed and 1 (1.1%) had mixed response. Survival data is immature with 62/101 (61.4%) patients alive at the time of census with median survival currently 6.5 months. Fatigue was the most frequent AE, with 69/88 patients (85.2%) for all grades. 12/88 patients (14.8%) had Grade 3 fatigue. Other significant AEs include hand-foot syndrome (6/85 patients [7.3%] had Grade 3) and diarrhoea (4/83 patients [4.9%] had Grade 3). Conclusions: The population in our real-world experience of regorafenib for HCC had a similar duration of prior sorafenib to those in the RESORCE trial. However, there was different balance of aetiologies with a lower proportion of patients with HBV and HCV. The rate of partial response is similar to the RESORCE trial with fewer patients achieving stable disease. The incidence of fatigue was higher, but the incidence of hand-foot syndrome and diarrhoea were lower. Further expansion and follow-up of this population is warranted.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Renal tubular dysfunction presenting as recurrent hypokalemic periodic quadriparesis in systemic lupus erythematosus

We report recurrent hypokalemic periodic quadriparesis in a 30-year-old woman. Patient had also symptoms of multiple large and small joint pain, recurrent oral ulceration, photosensitivity and hair loss that were persisting since last 6 months and investigations revealed systemic lupus erythematosus (SLE) with distal tubular acidosis. Our patient was successfully treated with oral potassium chloride, sodium bicarbonate, hydroxychloroquine and a short course of steroids. Thus, tubular dysfunction should be carefully assessed in patients with SLE.

Accuracy and applicability of the revised WHO classification (2009) of dengue in children seen at a tertiary healthcare facility in northern India

BACKGROUND

Revised case definitions of dengue into dengue with/without warning signs (DWS/D) and severe dengue (SD) was proposed by the World Health Organization (WHO)/Tropical Disease Research (TDR) in 2009. To date, there has been no Indian study that has applied this classification.

AIMS AND OBJECTIVES

To assess the accuracy and applicability of the revised WHO classification (2009) of dengue in children seen at a tertiary healthcare facility in India.

MATERIALS AND METHODS

Over a period of 1 year children from the pediatric ward and Out Patient Department (OPD) of the King George Medical University Hospital, Lucknow were enrolled in the study according to predefined criteria and tested for dengue. Each dengue-positive patient was classified according to both the older system [dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS)] and the new system (D, DWS, and SD). The severity of dengue was compared to the level of treatment received.

RESULTS

A total of 56 patients tested positive for dengue--51 from the pediatric ward and five from the OPD. According to the older WHO classification, 42 (75 %) patients were classified as DF and 13 (23.2 %) as DHF/DSS; one patient was unclassifiable. Five patients (8.9 %) received level 1 treatment, ten (17.8 %) received level 2 treatment, and 41 (73.2 %) received level 3 treatment. According to the new WHO/TDR classification, 46 (82.1 %) patients were classified as SD, nine (16 %) as DWS, and only one (1.7 %) as D. Many of the severe manifestations (encephalopathy, shock, mucosal bleed, platelet count <20,000, respiratory distress, liver enzymes >1,000 U/L) were seen in patients who were classified as DF according to old classification, whereas these patients were mostly classified as SD by the new classification. Sensitivity of the older and new classifications was 24.8 and 98 %, respectively.

CONCLUSIONS

The revised WHO/TDR (2009) classification has very high sensitivity for identifying severe dengue and is easy to apply.

Biomonitoring of metals in Ganga water at different ghats of Haridwar: implications of constructed wetland for sewage detoxification

An assessment of Ganga river water quality at different ghats of Haridwar, showed high TDS (782.15 mg L(-1)) and BOD (21.76 mg L(-1)) levels at the mixing points of sewage discharge channels and the water was found to be contaminated with appreciable amounts of toxic metals; Cu, Pb, Zn, Cr and Mn (0.178, 0.566, 0.199, 0.177 and 0.160 mg L(-1)). The Ganga water supported exuberant growth of algae and aquatic macrophytes in littoral zone of river, which accumulated appreciable amount of metals in their tissues. Results showed possibility of using metal accumulation potential of plants and algae for monitoring low level of metal contamination vis-a-vis their use in renovating sewage by treating into especially designed constructed wetland.

Progressive resistance training did not improve walking but can improve muscle performance, quality of life and fatigue in adults with multiple sclerosis: a randomized controlled trial

BACKGROUND

Few high-quality trials have examined the effects of progressive resistance training (PRT) on people with multiple sclerosis (MS).

OBJECTIVE

To determine the effectiveness of PRT for people with MS, focusing on improving the gait deficits common in this population.

METHODS

Using a single blind randomized controlled trial, people with relapsing-remitting MS were randomly allocated to either a PRT program targeting the lower limb muscles twice a week for 10 weeks (n = 36), or usual care plus an attention and social program conducted once a week for 10 weeks (n = 35). Outcomes were recorded at baseline, week 10 and week 22.

RESULTS

Participants attended 92% of training sessions, with no serious adverse events. At 10 weeks, no differences were detected in walking performance. However, compared with the comparison group PRT demonstrated increased leg press strength (16.8%, SD 4.5), increased reverse leg press strength (29.8%, SD 12.7), and increased muscle endurance of the reverse leg press (38.7%, SD 32.8). Improvements in favor of PRT were also found for physical fatigue (Mean difference -3.9 units, 95%CI -6.6 to -1.3), and the physical health domain of quality of life (Mean difference 1.5 units, 95%CI 0.1 to 2.9). At week 22 almost no between-group differences remained.

CONCLUSION

PRT is a relatively safe intervention that can have short-term effects on reducing physical fatigue, increasing muscle endurance and can lead to small improvements in muscle strength and quality of life in people with relapsing-remitting MS. However, no improvements in walking performance were observed and benefits do not appear to persist if training is completely stopped.

Acute intestinal obstruction: an unusual complication of mucocele of appendix

A rare case of intestinal obstruction due to compression of ileocecal junction by mucocele of appendix is presented. Imaging with ultrasound or computed tomography (CT) is useful in establishing preoperative diagnosis. Avoidance of rupture of during appendicectomy is critical in preventing potential complication of pseudomyxoma peritonei.

Progressive resistance exercise for people with multiple sclerosis

PURPOSE

This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS).

METHODS

A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 - 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14.

RESULTS

Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02).

CONCLUSIONS

Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.

A qualitative analysis of a progressive resistance exercise programme for people with multiple sclerosis

PURPOSE

This qualitative study explored the perceptions of adults with multiple sclerosis about the positive and negative effects of a progressive resistance strengthening programme; and identified factors that might facilitate or create barriers to participation.

METHODS

Seven women and two men (mean age 45.6 years, SD 10.7) with multiple sclerosis participated in a 10-week gymnasium based progressive resistance strengthening programme held twice a week. Participants were interviewed at the end of the programme. The recorded interviews were transcribed and then independently coded by three researchers. From these codes, the main themes emerged.

RESULTS

Reports about the programme were very positive with physical, psychological and social benefits noted. Most participants said that they had less fatigue as a result of the programme. Few negative outcomes were reported and these were minor such as aches and pains. Key extrinsic factors for programme completion were the leaders' encouragement and knowledge of exercise; and the group aspect of the programme. Key intrinsic factors were enjoyment, determination, seeing the signs of progress, and a previously held positive attitude about the benefits of exercise.

CONCLUSIONS

The results of this study suggest that progressive resistance strength training is a feasible fitness option for some people with multiple sclerosis. Factors perceived to be important for programme completion suggest that choosing encouraging leaders with knowledge of exercise, and exercising in a group may contribute to programme success.

Acetyl-l-carnitine (ALCAR) prevents hypobaric hypoxia-induced spatial memory impairment through extracellular related kinase-mediated nuclear factor erythroid 2-related factor 2 phosphorylation

Exposure to hypobaric hypoxia, a condition involving decreased availability of oxygen is known to be associated with oxidative stress, neurodegeneration and memory impairment. The multifactorial response of the brain and the complex signaling pathways involved therewith limits the therapeutic efficacy of several antioxidants in ameliorating hypobaric hypoxia-induced memory impairment. The present study was therefore aimed at investigating the potential of acetyl-l-carnitine (ALCAR), a known antioxidant that has been reported to augment neurotrophin-mediated survival mechanisms, in ameliorating hypoxia-induced neurodegeneration and memory impairment. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key transcription factor involved in the cellular defense mechanism against oxidative stress related to brain injury and neurological disorders. The study was designed to understand the mechanisms involving Nrf2 stabilization following exposure to hypobaric hypoxia. The results displayed reference memory impairment in Sprague-Dawley rats exposed to hypobaric hypoxia (7620 m) for 14 consecutive days which however improved on administration of ALCAR during hypoxic exposure. The study also revealed Nrf2 regulated augmented antioxidant response on administration of ALCAR which was through a novel tyrosine kinase A (TrkA) receptor-mediated mechanism. A decrease in free radical generation, lipid peroxidation and protein oxidation was also observed along with a concomitant increase in thioredoxin and reduced glutathione levels on administration of ALCAR during exposure to hypobaric hypoxia. The present study therefore reveals the therapeutic potential of ALCAR under conditions of hypobaric hypoxia and elucidates a novel mechanism of action of the drug.

Removal of sulphates acidity and iron from acid mine drainage in a bench scale biochemical treatment system

The focus of this study was to develop a simple biochemical system to treat acid mine drainage for its safe disposal. Recovery and reuse of the metals removed were not considered. A three-step process for the treatment of acid mine drainage (AMD), proposed earlier, separates sulphate reducing activity from metal precipitation units and from a pH control system. Following our earlier work on the first step (biological reactor), this paper examines the second step (i.e. chemical reactor). The objectives of this study were: (1) to determine the increase in pH and the reduction of iron in the chemical reactor for different proportions of simulated AMD, and (2) to assess the capability of the chemical reactor. A series of experiments was conducted to study the effects of addition of alkaline sulphidogenic liquor (ASL) derived from a batch sulphidogenic biological reactor (operating with activated sludge and a COD/SO4 ratio of 1.6) on the simulated AMD characteristics. At 60-minute contact time, addition of 30% ASL (pH of 7.60-7.76) to the chemical reactor with 70% AMD (pH of 1.65-2.02), increased the pH of the AMD to 6.57 and alkalinity from 0 to 485 mg l(-1) as CaCO3, respectively and precipitated about 97% of the iron present in the simulated AMD. Others have demonstrated that metals in mine drainage can be precipitated by bacterial sulphate reduction. In this study, iron, a common and major component of mine drainage was used as a surrogate for metals in general. The results indicate the feasibility of treating AMD by an engineered sulphidogenic anaerobic reactor followed by a chemical reactor and that our three-step biochemical process has important advantages over other conventional AMD treatment systems.

Mechanism of tert-butylhydroperoxide induced cytotoxicity in U-937 macrophages by alteration of mitochondrial function and generation of ROS

tert-Butylhydroperoxide has been reported to inhibit growth and induce apoptosis in number of cell types, but little is known about the molecular mechanism mediating these effects. In the present study, we determined the molecular pathways that lead to apoptosis after treatment of cells with t-BOOH. The cells were exposed to different concentrations of t-BOOH (100-750 microM) for 1-4 h and various parameters such as cytotoxicity, ROS (reactive oxygen species) generation, MMP (mitochondrial membrane potential), intracellular Ca++ levels and expression of various proteins involved in apoptosis were determined. Exposure of U-937 cells to t-BOOH induced cytotoxicity in a time dependent manner with about 50% toxicity at 400 microM t-BOOH in 4h. t-BOOH treatment resulted in a time dependent increase in reactive oxygen species levels, Ca++ influx and annexin V positive cells. There was a significant fall in MMP following exposure to t-BOOH with time. t-BOOH treatment of U-937 cells leads to apoptosis, which is accompanied by activation of caspase-3. The caspase-3 inhibitor (Ac-DEVD-CHO) inhibits the cytotoxicity induced by t-BOOH, indicating a direct link between caspase-3 activation and cell death. This activation of apoptosis is accompanied by release of cytochrome c, down regulation of anti-apoptotic protein Bcl-2 levels with concurrent increase in pro-apoptotic proteins Bax and Bad levels. These observations indicate that t-BOOH induces cell death in U-937 macrophages by apoptosis, which is mediated through mitochondrial pathway.

Direct electron transfer with yeast cells and construction of a mediatorless microbial fuel cell

The direct electron transfer exhibited by the yeast cells, Hansenula anomala has been demonstrated using the electrochemical technique cyclic voltammetry by immobilizing the microorganisms by two different methods viz., physical adsorption and covalent linkage. The analysis of redox enzymes present in the outer membrane of the microorganisms has been carried out in this work. This paper demonstrates that yeast cells with redox enzymes present in their outer membrane are capable of communicating directly with the electrode surface and contribute to current generation in a mediatorless biofuel cells. The efficiency of current generation has been evaluated using three anode materials.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.

Biosolids from two-stage bioleaching could produce compost for unrestricted use

A biological process, called BIOSOL, developed in our laboratory, efficiently reduces metals and reduces pathogenic indicator bacteria in sewage sludges in a single-stage system to levels meeting Ontario Ministry of the Environment (OME) requirements for land application of biosolids. Since the requirements for unrestricted use of compost are 10 to 50 times (depending on the metal involved) more restrictive than those for land application, this study was carried out to determine whether the efficiency of the BIOSOL system could be increased to meet the more stringent limitations required for compost. A two-stage modified BIOSOL system was successfully operated for a period of 4% months, at 30 degrees C, treating anaerobically digested sludge from the Guelph Wastewater Treatment Plant. Elemental sulphur (4g l(-1)) was the energy source for the autotrophic bacteria (thiobacilli). The pH, metals (Cd, Cr, Cu, Pb and Zn), and sulphate were used to evaluate system effectiveness. At an HRT of 8 days in each solubilization tank, and a S*-concentration of 4g l(-1), sulphur oxidation efficiency was about 70%, while the metal removals were: Cd 90%, Cr 93%, Cu 96%, Pb 67% and Zn 98%. The finished product (biosolids) met the OME requirements for metal concentrations for producing compost or fertilizer for unrestricted use. The reduction of pathogenic indicator organisms was demonstrated in earlier studies.

A biological process that reduces metals in municipal sludge to yield sulphur enhanced biosolids

Heavy metal contamination can often restrict or prohibit land application of municipal sludge. In the present investigation a continuous biological process with powdered elemental sulphur as energy source was examined for solubilization of metals from anaerobically digested municipal sludge. The results showed that the continuous process can be designed to achieve both metal solubilization and efficient sulphur utilization. With a sulphur addition of 1.5 g l(-1) and an HRT of 14 days, solubilization efficiencies of 50, 33, 48, and 74% were obtained for cadmium, copper, nickel, and zinc, and about 80% of the added sulphur was oxidized. Addition of ferrous sulphate as an additional energy source did not improve the performance of the process. The residual sulphur in the metal decontaminated biosolids was in balance with the phosphorus content, potentially making it an effective sulphur fertilizer for soils deficient in the nutrient.

Cytoprotective and antioxidant activity of Rhodiola imbricata against tert-butyl hydroperoxide induced oxidative injury in U-937 human macrophages

The present study reports cytoprotective and antioxidant activity of aqueous and alcoholic extracts of Rhodiola imbricata rhizome on tert-butyl hydroperoxide (tert-BHP) induced cytotoxicity in U-937 human macrophages. There was an increase in cytotoxicity and apoptosis significantly in the presence of tert-BHP over control cells. The tert-BHP induced cytotoxicity can be attributed to enhanced reactive oxygen species (ROS) production which in turn is responsible for fall in reduced glutathione (GSH) levels; further there was a significant decrease in mitochondrial potential and increase in apoptosis and DNA fragmentation. Both aqueous and alcoholic extracts of Rhodiola rhizome at a concentration of 250 microg/ml were found to inhibit tert-BHP induced free radical production, apoptosis and to restore the anti-oxidant levels to that of the control cells. The alcoholic extract of Rhodiola showed higher cytoprotective activities than aqueous extract. These observations suggest that the alcoholic and aqueous extracts of Rhodiola have marked cytoprotective and antioxidant activities.

Intracranial subfrontal schwannoma treated with surgery and 3D conformal radiotherapy

Subfrontal schwannoma not arising from the cranial nerves are rare tumors. A 19-year-old man presented with a large subfrontal extra-axial enhancing mass with a preoperative diagnosis of skull base meningioma. A subtotal resection of the tumor mass was carried out. Microscopic examination revealed it to be a schwannoma. The residual tumor was treated with fractionated three-dimensional conformal radiotherapy (3D CRT). The rationale of treating with radiotherapy in such cases is analyzed.

Targeted cybridization in citrus: transfer of Satsuma cytoplasm to seedy cultivars for potential seedlessness

CMS (cytoplasmic male sterility) can be controlled by the mitochondrion genome in higher plants, including Satsuma mandarin. Somatic fusion experiments in citrus combining embryogenic callus protoplasts of one parent with leaf protoplasts of a second parent often produce cybrid plants of the leaf parent, a phenomenon occurring most often with interspecific fusion combinations. In an attempt to practically exploit this cybridization phenomenon, we conducted somatic fusion experiments combining embryogenic suspension-derived protoplasts of Satsuma mandarin, Citrus unshiu Marc. cv. Guoqing No. 1 (G1), a male-sterile cultivar, with leaf protoplasts of other seedy types--Hirado Buntan Pink pummelo (HBP) [Citrus grandis (L.) Osbeck], Sunburst mandarin (C. reticulata Blanco), Orie Lee hybrid (C. reticulata cv. Clementine x Murcott tangor), and Murcott tangor [C. reticulata x C. sinensis (L.) Osbeck], respectively--in an attempt to generate seedless cybrids by the targeted transfer of CMS. The genetic identities of regenerated plants from all four parental combinations were determined by flow cytometry, SSR, CAPS (or PCR-RFLP), RFLP, and chloroplast-SSR analyses. Regenerated plants from the first three parental combinations were diploids, and the cybrid nature of G1 + HBP with the mitochondrion genome from G1 and the chloroplast genome from HBP was confirmed, whereas the cybrid nature of the remaining two combinations was difficult to confirm because of the close phylogenetic relatedness of both fusion parents, as expected. Plants from G1 + Murcott were confirmed as tetraploid somatic hybrids. This is the first report of targeted citrus cybrid production by symmetric fusion with male-sterile Satsuma as the callus parent and other seedy cultivars as the leaf parents.

Cytoprotective and immunomodulatory properties of Geriforte, a herbomineral preparation, in lymphocytes

The study was designed to determine the cytoprotective and immunomodulatory properties of Geriforte, an indigenous herbomineral compound, using lymphocytes as a model system. The possible involvement of free radicals and the ability of Geriforte to inhibit the oxidative process induced by tert-butylhydroperoxide (tert-BHP) was also investigated. The production of free radicals (evaluated by fluorescent probe fluorescein-diacetate), level of malondialdehyde (MDA, as index of lipid peroxidation), and levels of anti-oxidants--reduced glutathione (GSH) and glutathione peroxidase (GPx) were determined. There was an increase in cytotoxicity and apoptosis significantly in the presence of tert-BHP (100 microM) over control. Addition of tert-BHP resulted in a marked increase in free radical production and MDA level with a concomitant decrease in GSH level in lymphocytes. Geriforte supplementation reduced cytotoxicity and apoptosis induced by tert-BHP. Further, Geriforte inhibited tert-BHP induced lipid peroxidation and maintained higher anti-oxidant levels. tert-BHP significantly inhibited the lymphocyte proliferation stimulated by mitogens (Lipopolysaccharide/Concanavalin A) and enhanced DNA fragmentation. Geriforte relieved the inhibitory effect of tert-BHP on lymphocyte proliferation and decreased DNA fragmentation appreciably. The results indicate that Geriforte possesses cytoprotective and immunomodulatory properties which could be due to its anti-oxidant activity.

Effect of vitamin E supplementation on hypoxia-induced oxidative damage in male albino rats

BACKGROUND

There is growing evidence that free radicals mediated oxidative injury due to inadequate oxygen availability is an important factor in various pathologies at high altitude. Since vitamin E is known to protect the cells from oxidative damage due to its potent antioxidant properties, the present study was carried out to explore the effect of vitamin E supplementation on various hematological and biochemical parameters in hypoxia-induced oxidative stress in albino rats.

METHODS

The experiments were conducted on male albino rats by intermittently exposing them to a simulated altitude of 7,576 m (25,000 ft), daily for 6 h for 15 d at 32 +/- 2 degrees C. The control group was fed vehicle only (1% Tween 80) and the experimental group was given vitamin E (40 mg per rat x d(-1)) orally, 5 d prior to and during the period of hypoxic exposure. The variables studied include: hemoglobin, hematocrit, RBC deformability index, alpha-tocopherol level, malondialdehyde (MDA), reduced glutathione (GSH), oxidized glutathione (GSSG), lactate dehydrogenase (LDH) and protein level in blood/plasma and various tissues.

RESULTS

Significant increase in hematocrit and hemoglobin and decrease in RBC deformability index was observed on exposure to hypoxia while vitamin E supplementation maintained them at the normal level. Hypoxia led to the decrease in plasma vitamin E and blood glutathione (GSH) level and two-fold increase in the plasma malondialdehyde (MDA) level. Vitamin E supplementation, on the other hand, resulted in less of an increase in MDA and increased the GSH concentration significantly. LDH activity, which was elevated on exposure to hypoxia, was arrested on vitamin E supplementation.

CONCLUSION

The results indicate that vitamin E supplementation results in preventing oxidative damage due to high altitude stress.

Reduction of indicator organisms during biological solubilization of metals: a pilot study

Laboratory and pilot scale studies on the biological solubilization of metals from undigested raw sludge were carried out using elemental sulphur as the energy source. Metals (Cu, Zn, Ni and Cd), pH, sulfate and indicator bacteria [total coliforms (TC) faecal coliforms (FC) and faecal streptococci (FS)] were used to evaluate the system effectiveness. This paper does not report the detailed design and operational data of the pilot plant (available elsewhere [1]) but focuses on the biological tests carried out at the Main Wastewater Treatment Plant in Toronto from July to December, 1997. Since the indicator bacteria are injured from exposure to low pH and potentially toxic metal concentrations, improved alternative methods for their enumeration and their ability to repair acid-metal induced injury in a resuscitation medium (CASO tryptone soya broth) were also investigated. Resuscitation was not effective in repairing cells injured during bacterial leaching. The MPN technique (using lauryl tryptose broth) for enumerating indicator bacteria (total coliforms) gave higher counts and was therefore superior to the spread plate technique (using m-Endo agar) in recovering bacteria from acidic leached sludge (biosolids). However, the coliform bacterial counts from raw sludge were similar by the two methods. This study indicated that the biological solubilization process could significantly reduce the pathogenic indicators. Concentrations of TC, FC and FS in the leached biosolids from the solubilization tank were lower than concentrations in the raw sludge by 4 to 6 orders of magnitude and the finished product (biosolids) met US. EPA requirements for pathogen and metal concentrations for Class A biosolids to be used on agricultural land.