Effect of fenugreek and flaxseed polysaccharide-based edible coatings on the quality attributes and shelf life of apple fruit during storage

The present study was designed to explore the potential of fenugreek and flaxseed polysaccharide-based edible coatings to enhance the postharvest storage life of apple fruit. The experimental plan involved the preparation of five different coating formulations, which were subsequently applied to the fruit. The coated fruit was then stored at a temperature of 25 ± 2°C for a duration of 35 days. The effects of these coatings on physicochemical and biochemical attributes (weight loss, firmness, acidity, pH, sugar content, antioxidant activity, microbial growth, and sensory properties) of coated and uncoated samples were evaluated at regular intervals: 0, 7, 14, 21, 28, and 35 days of storage. The experimental results revealed a significant difference (p ≤ .05) in the physicochemical parameters of uncoated and coated apple at different storage times. The coated apple fruits showed significantly (p ≤ .05) lower weight loss, pH, total sugars, total soluble solids, and maximum retention of ascorbic acid, firmness, acidity, and antioxidant contents, leading to enhanced organoleptic properties. The application of edible coatings extended the shelf-life of the apples by inhibiting microbiological spoilage without substantial impact on sensory and nutritional properties. Based on these results, it is concluded that the edible coating formulation labeled T 1 (containing 2.5 g fenugreek polysaccharide and 1.5 g flax polysaccharide) effectively preserved the valuable physicochemical and organoleptic characteristics of the apple fruit throughout the storage period.

Association of Posterior Reversible Encephalopathy Syndrome (PRES) with Preeclampsia with Severe Symptoms and Eclampsia in South East Part of Bangladesh

Posterior reversible encephalopathy syndrome (PRES) is a pathology seen not only in precelampsia with severe symptoms and eclampsia but in a varicty of diseases/ conditions. With the availability of neuroimaging, it is possible to know the exact underlying Central nervous system (CNS) pathology in preeclampsia with severe symptoms and eclampsia and thus therapy can be targeted. Preeclampsia with severe symptoms and eclampsia remains to be an important cause of maternal morbidity and mortality in both the developing and developed world. The objective of this study was to evaluate the association of Posterior reversible encephalopathy syndrome (PRES) by MRI (Magnetic resonance imaging) with preeclampsia with severe symptoms and eclampsia in south east part of Bangladesh. This cross-sectional observational study was performed among women suffering from preeclampsia with severe symptoms and eclampsia who attended at Obstetrics & Gynaecology department of Chittagong Medical College Hospital (CMCH), Bangladesh from January 2021 to June 2021. According to inclusion/exclusion criteria 50 samples were taken by convenient sampling for this study. A detail history was taken and complete general physical and gynecological examination was performed. Required data was collected through preset questionnaire. Neuroimaging reports were reviewed by both neurologist and radiologist. Data was analyzed by using windows based computer software device, SPSS 25.0. Results obtained from this study will be used to make a statement regarding aggressive management for cerebral vasospasm in severe preeclampsia and eclamptia related PRES. PRES has been reported to be reversible but late recognition or incorrect treatment can cause irreversible brain damage. Institution of early treatment leads to resolution of symptoms without any neurologic deficit and thus reduces maternal morbidity and mortality. PRES is a cliniconeuroradiologic entity. This study can aware doctors regarding prompt diagnosis of PRES in peripartum period among patient suffering from preeclampsia with severe symptoms and eclampsia by imaging aside clinical findings. A conclusive decision can be made to improve the outcome in this potentially life threatening but reversible condition.

Non-Puerperal Chronic Inversion of Uterus Due to Big Fibroid Uterus in a Post-Menopausal Woman

Uterine inversion occurs in puerperal and non-puerperal conditions; non-puerperal uterine inversion (NPUI) may run acute and chronic clinical course. Most on the NPUI are chronic variety while a few are acute variety. NPUI occurs if there is long standing big sub-mucosal fibroid and it is very rare to present in acute setting. Here we report a case of acutely presented NPUI. A 58-year-old widow of lower socioeconomic status presenting to the emergency center of Chittagong medical college Hospital with complaints of sudden protrusion of a big mass through introitus in an attempt of passing out hard stool during defecation on the day of admission with a history of per vaginal watery discharge for a long time and severe anemia. Anemia was corrected and a broad-spectrum antibiotic was given prior to operative management. Under general anesthesia vaginal myomectomy followed by vaginal hysterectomy was performed in the same sitting. Pathological examination revealed a fibroid uterus. Postoperatively patient recovered without any residual problem. Infection should be suspected and treated with appropriate broad-spectrum antibiotics before planning surgery. Vaginal route restoration of NPUI is very difficult but possible with careful attempt. During a vaginal hysterectomy, care to locate and salvage the bladder and distal urinary collecting system is warranted. So, a high index of suspicion is the key to limit morbidity and approach for proper management of such rare clinical condition.

Morphological, cytogenetic and molecular characterisation of FLT3 mutations in Pakistani patients with de novo acute myeloid leukaemia: A single centre experience

INTRODUCTION

Mutations in FLT3 are the most commonly reported genetic changes in AML patients. These mutations are normally identified in approximately one third of newly diagnosed patients and are reported to have prognostic significance.

MATERIALS AND METHODS

Peripheral blood samples was collected from 63 AML patients to study their morphological, cytogenetic and molecular features. PCR was used to determine the prevalence of FLT3 mutations; internal tandem duplication (ITD) and tyrosine kinase domain (TKD) in AML patients.

RESULTS

Among 63 AML patients, 42 were males and 21 were females with male to female ratio 2:1 with median age of 32 years. AML-M2 was the predominant French-American-British (FAB) subtype (42%) followed by M4 (27%), M3 (8%), M1 (8%), M0 (8%) and M5 (7%) respectively. Cytogenetic analysis of 60 patients showed 58% as cytogenetically normal (CN) whereas 42% had aberrant karyotype.The most frequent aberrations were trisomy8, t(8;21), t(15;17) (8.3%) each, inversion16 (5%), and different deletions (12%) respectively. FAB-M4 subtype showed most of the chromosomal anomalies. Among 63 AML patients, 22% showed FLT3/ITD while 6.4% had D835 mutation after molecular analysis. FLT3 mutations were found in most of the FAB subtypes and cytogenetic groups. FLT3/ITD mutations were more common in patients with normal karyotype (26%) and usually present with hyperleukocytosis but association between two was not significant.

CONCLUSION

The cytogenetic data of adult AML from Pakistan showed presence of favourable prognostic karyotype with comparable prevalence as reported in international data. Moreover, FLT3/ITD mutations are commonly found in our patients as determined by molecular analysis. Therefore, inclusion of this unfavourable prognostic marker should be routine in molecular diagnostic testing of AML.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Concordance and Discordance of Mitotic Count, Ki-67 Proliferative Index and Phosphohistone H3 Count in Grading Neuroendocrine Tumors of Gastrointenstinal Tract

Objective: To determine the grades of gastrointestinal neuroendocrine tumours using World Health Organization criteria and Phosphohistone H3 mitotic index and to determine the concordance between the two methods. Study Design: Cross-sectional study. Place and Duration of Study: Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi Pakistan, from Mar to Oct 2019. Methodology: Forty-two (n=42) patients of either gender between the ages of 18-70 years were enrolled. All the enrolled patients were diagnosed with primary gastrointestinal neuroendocrine tumours and underwent either surgical or endoscopic resection. Tumour grades were determined using World Health Organization criteria and Phosphohistone H3mitotic index. The results obtained with both methods were compared, and the concordance rate was calculated. Results: When mitotic counts were determined through PHH3, MI resulted in a change of grade of 12 (28.6%) tumours, which were graded by the current WHO system. 11 (26.2%) were changed from grade II to grade I and 1 (2.4%) from grade I to grade I1. The agreement (concordance rate) between the two systems was moderate and statistically significant (71.4%, n=30/42, κ= 0.51, p= 0.001). Conclusion: In the present study, we observed a moderate agreement between the Ki-67 labelling index and the PPH3 mitotic index, and both correlate well with the mitotic counts. The PPH3 mitotic index demonstrated a better correlation with mitotic counts when compared with Ki-67 LI. Hence, the inference can be drawn that the mitotic index with Phosphohistone H3is associated more closely with mitosis in gastrointestinal neuroendocrine tumours.

Comparison of Breast Biopsy Pathology Reporting with Breast Imaging Reporting and Data System (Bi-Rads) Categories-An Institutional Study

Objective: To determine concordance and discordance between radiological and pathological findings of palpable breast lesions. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi Pakistan, from Oct 2018 to Mar 2019. Methodology: Imaging and histopathologic reports of a total of 170 female patients with breast lumps were analyzed. Concordance and discordance rates were estimated by comparing histopathology and imaging findings. All the reports were divided into four categories. Malignant concordant lesions showed malignant features and benign concordant lesions showed benign features on both imaging and histopathology. Malignant discordant lesions were those lesions, which were reported benign on imaging but proved to be malignant on histopathology and benign discordant lesions were those showing malignant features on imaging but turned out to be benign on histopathology. Results: Overall concordance was observed in 138 (81.2%) cases with a discordance rate of 18.8% (15.3% benign discordant and 3.5% malignant discordant). All malignant discordant cases (n=6, 3.5%) were reported as Breast Imaging Reporting and Data System category III on imaging and all came out to be invasive ductal carcinoma on histopathology. All benign discordant cases (n=26, 15.3%) were reported as Breast Imaging Reporting and Data System category IV on imaging. Conclusion: A higher discordance rate between imaging and histopathologic findings was observed in the present study as compared to what cited in the literature. Discordant cases should be followed by repeat biopsy for confirmation of diagnosis

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Frequency of Expression of BRAF V600E and Epidermal Growth Factor Receptor (EGFR) in Ameloblastoma

Objective: To determine the Immunohistochemical expression of BRAF V600E and Epidermal growth factor receptor (EGFR) in ameloblastoma and correlate the expression with age and gender of patients, and patterns and types of ameloblastoma. Material & Methods: 39 cases were retrieved with their formalin-fixed, paraffin embedded blocks, trimmed and cut into 5 microns sections. They were mounted on slides after staining with routine hematoxylin and eosin followed by Immunohistochemical staining of BRAF V600E and EGFR. Mean and standard deviation were calculated for quantitative variables. Frequency and percentages were calculated for qualitative variables. Chi-square test was employed to assess the significance of difference. The p-value ≤ 0.05 was considered significant. Results: There were 19 (41.2%) males and 20 (48.7%) female patients. The mean age of patients at which they presented was 39.97 ± 15.505 (mean ± SD) with an age range between 12 to 65 years. 25 (64.1 %) cases showed positive expression of BRAF V600E and 14 (35.8 %) cases showed negative expression of BRAF V600E. 27 (69.2 %) cases showed positive expression of EGFR whereas 6 (15.3 %) cases showed negative expression of EGFR. The p-value was ≤ 0.05 for expression of BRAF V600E with respect to patterns of ameloblastoma and tumor site and expression of EGFR with respect to sub-types of ameloblastoma.Conclusion: There is positive expression of BRAF V600E (64.1%) and EGFR (74.4%) in different sub-types and patterns of ameloblastoma. Correct assessment with the help of these markers can lead to early diagnosis and use of adjuvant treatment protocols

Frequency of Expression of PD-1 andPD-L1 In Head And Neck Squamous Cell Carcinoma And their Association With Nodal Metastasis: A Cross-Sectional Study

Objective:

The objective of this study was to determine the Immunohistochemical expression of PD- 1, PD-L1 and its association with nodal metastasis in head and neck squamous cell carcinoma.

Materials and Methods:

A total of 66 cases were studied at Oral pathology/Histopathology, Armed forces Institute of Pathology (AFIP), Rawalpindi. The tissue sampling and processing yielded the formalin fixed, paraffin wax blocks. These blocks were cut into the thin sections (5 microns) by the microtome and then were mounted on the glass slides. This was followed by the routine H&E staining and then IHC staining (PD-1 and PD-L1) of these tissues mounted slides. For each case a definitive histological diagnosis was made. The two types of variables were analyzed. For qualitative variables frequencies and percentages were calculated whereas for quantitative variables means and standard deviations were analyzed. The Chi-square test then was applied to evaluate the significant difference and p-value of ≤0.05 was taken significant.

Results:

This study was conducted at Histology department, Armed Forces Institute of Pathology, Rawalpindi over a period of one year from June 2019 to June 2020. It revealed male and female patients with 66.7% (44 Cases) and 33.3% (22cases) percentages respectively. The mean age was found to be 59.53 ± 13.637 (mean ± SD) and the mandible (37.9%) was the most commonly affected site. In total of 66 cases, 48 (72.7%) cases with metastasis of lymph nodes were presented. Out of 66 cases ,47 (71.2%) cases showed positive expression of PD-1 in the TILs seen among the primary tumor of the specimens, whereas, 40 (60.6%) cases showed positive PD-L1 expression in tumor cells of primary tumor.In comparison, as out of 66 cases ,48 (72.5%) cases showed lymph nodes metastasis, out of which 45 showed positive expression for PD-1 and 25 out of those 48 cases showed positive expression for PD-L1 in metastatic lymph nodes.The p-value turned to be significant for PD-1 IHC expression and PD-L1 IHC expression in the primary tumorand metastatic lymph nodes.

Conclusion:

A significant correlation was inferred among IHC expression of PD-1 and PD-L1 with lymph nodes metastasis. Accurate evaluation, analysis and precise management with aid of IHC markers results in initial and timely diagnosis and favorable treatment outcomes helping in the evaluation of disease course at preliminary diagnosis on incisional biopsies.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

614 Elective Bariatric and Metabolic Surgery in United Kingdom During the Coronavirus Pandemic

Aim

Elective Bariatric and Metabolic Surgery (BMS) was halted in the UK during the first wave of the Coronavirus (COVID-19) pandemic. Obesity is a predictor of poor outcome in those infected with this virus. This study reports our experience resuming elective weight loss surgery safely amidst the pandemic.

Method

Guidance from national bodies (BOMSS/NICE) were reviewed and a Standard Operating Procedure (SOP) was drafted to accommodate local considerations. Data were prospectively collected on patients undergoing BMS following commencement of elective surgery after the first national lockdown.

Results

A total of 50 patients underwent BMS at our institution within six weeks of resuming the services. The median age was 41 years old and BMI was 43.8(IQR 40.0-48.8 kg/m2). Equal number of patients underwent laparoscopic Sleeve Gastrectomy (SG) and Roux en-Y Gastric Bypass (RYGB). Of these, 9 patients (18%) had revisional surgery and 48 patients (96%) were discharged within 24 hours of their surgery. The rate of readmission within thirty days of surgery was 6% (n = 3) and 1 patient returned to theatre with an obstruction proximal to the jejuno-jenunal anastomosis. None of the patients exhibited symptoms or tested positive for the COVID-19 virus.

Conclusions

With appropriate precautions and protocols, it is feasible and safe to resume BMS, with no increased risk to bariatric patients during the COVID-19 pandemic. This is particularly encouraging for other units in UK to offer BMS after the current lockdown.

Gut dysbiosis, inflammation and type 2 diabetes in mice using synthetic gut microbiota from diabetic humans

The study was aimed to assess impact of high fat diet (HFD) and synthetic human gut microbiota (GM) combined with HFD and chow diet (CD) in inducing type-2 diabetes (T2D) using mice model. To our knowledge, this is the first study using selected human GM transplantation via culture based method coupled dietary modulation in mice for in vivo establishment of inflammation leading to T2D and gut dysbiosis. Twenty bacteria (T2D1-T2D20) from stool samples of confirmed T2D subjects were found to be morphologically different and subjected to purification on different media both aerobically and anerobically, which revealed seven bacteria more common among 20 isolates on the basis of biochemical characterization. On the basis of 16S rRNA gene sequencing, these seven isolates were identified as Bacteroides stercoris (MT152636), Lactobacillus acidophilus (MT152637), Lactobacillus salivarius (MT152638), Ruminococcus bromii (MT152639), Klebsiella aerogenes (MT152640), Bacteroides fragilis (MT152909), Clostridium botulinum (MT152910). The seven isolates were subsequently used as synthetic gut microbiome (GM) for their role in inducing T2D in mice. Inbred strains of albino mice were divided into four groups and were fed with CD, HFD, GM+HFD and GM+CD. Mice receiving HFD and GM+modified diet (CD/HFD) showed highly significant (P<0.05) increase in weight and blood glucose concentration as well as elevated level of inflammatory cytokines (TNF-α, IL-6, and MCP-1) compared to mice receiving CD only. The 16S rRNA gene sequencing of 11 fecal bacteria obtained from three randomly selected animals from each group revealed gut dysbiosis in animals receiving GM. Bacterial strains including Bacteroides gallinarum (MT152630), Ruminococcus bromii (MT152631), Lactobacillus acidophilus (MT152632), Parabacteroides gordonii (MT152633), Prevotella copri (MT152634) and Lactobacillus gasseri (MT152635) were isolated from mice treated with GM+modified diet (HFD/CD) compared to strains Akkermansia muciniphila (MT152625), Bacteriodes sp. (MT152626), Bacteroides faecis (MT152627), Bacteroides vulgatus (MT152628), Lactobacillus plantarum (MT152629) which were isolated from mice receiving CD/HFD. In conclusion, these findings suggest that constitution of GM and diet plays significant role in inflammation leading to onset or/and possibly progression of T2D. .

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19

INTRODUCTION

Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients.

METHODS

A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK.

RESULTS

Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19.

CONCLUSION

With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Childhood cancers: Analysis of 1279 cases at Armed Forces Institute of Pathology, Rawalpindi, Pakistan

OBJECTIVE

To determine the clinicopathological pattern of childhood malignancies registered with a pathology-based tumour registry.

METHODS

The descriptive retrospective study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, and comprised data related to all the histologically diagnosed malignant childhood tumours in the institutional tumour registry from January 2009 to December 2018. Data was analysed using SPSS 20 for the site of involvement, age distribution and histological types of tumours.

RESULTS

Of the total 37793 malignant tumours, 1279(3.38%) were in paediatric subjects aged <15 years. There were 820(64.1%) male subjects and 459(35.8%) were female. Lymph node malignancies were the commonest 261(20.4%), followed by eye tumours 251(19.6%), and brain 107(8.3%).

CONCLUSIONS

Lymphomas and eye tumours were found to form the main bulk of childhood cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

26 COVID-19 Diagnosis in Patients with Acute Abdominal Pain Without Respiratory Symptoms: A UK Emergency General Surgical Unit Experience

Introduction

Evidence has emerged reporting atypical symptoms of the coronavirus (COVID-19). There is a sparsity of existing studies examining COVID-19 related abdominal pain and the role of investigative imaging for the virus in these patients. Study aims were to determine COVID-19 incidence in those with acute abdominal pain in the absence of respiratory symptoms and to assess the performance of Computer Tomography (CT) thoracic imaging.

Method

Retrospective analysis of all patients admitted to our emergency general surgical unit between 1^st March 2020 and 31^st May 2020 was performed. All patients underwent nasal and oro-pharyngeal COVID-19 RT-PCR swabs as well as CT on admission.

Results

From 112 patients admitted with acute abdominal pain in the absence of respiratory symptoms, 16 (14.3%) tested positive for COVID-19 on RT-PCR swab testing. 50% (8/16) of these patients had no intra-abdominal pathology on CT. The sensitivity and specificity of CT thoracic imaging for COVID-19 was 43.8% and 91.7%.

Conclusions

One in seven patients with abdominal pain without any respiratory symptoms tested positive. Half these patients represented COVID-19 manifesting primarily as acute abdominal pain. Combined swab testing and CT imaging should be performed in all abdominal pain presentations due to the varying diagnostic performance of thoracic CT in diagnosing COVID-19.

Effect of high voltage atmospheric cold plasma on extraction of fenugreek galactomannan and its physicochemical properties

Fenugreek is a good source of galactomannan, however, conventional methods for its extraction are generally time-consuming and have relatively low recovery rates. In this study, we applied high voltage atmospheric cold plasma (HVACP) as a pretreatment and investigated its effects on galactomannan extraction from dry fenugreek seeds and soaked seeds in NaCl solution, as well as its physicochemical properties. Results showed that HVACP treatment with air at 80 kV for 30 min caused apparent structural disruption on fenugreek seed surface and decreased the pH of extracting solution, resulting in increased galactomannan extraction yields, by 122% from soaked seeds and 67% from dry seeds. Galactomannan treated with HVACP had higher water-binding capacity, swelling index and viscosity, as well as lower melting enthalpy. HVACP treatment also altered the surface morphology of galactomannan due to plasma etching, but no significant changes in its molecular and crystalline structures were observed. The findings of this study prove that HVACP can be a green approach, in terms of reduced chemical use, to effectively enhance the extraction efficiency of fenugreek galactomannan and modify its functional properties, hence facilitate more diverse applications in both food and polymer industries.

The α2,3-selective potentiators of GABAA receptors, KRM-II-81 and MP-III-80, produce anxiolytic-like effects and block chemotherapy-induced hyperalgesia in mice without tolerance development

Opiate analgesics are one of the treatment options for severe chronic pain, including late-stage cancer, chronic back pain and other disorders. The recent resurgence in opioid overdose has highlighted the serious need for alternative medicines for pain management. While a role for potentiators of α2/3-containing GABA_A receptors in the modulation of pain has been known for several years, advancements in this area required data from selective compounds. KRM-II-81(5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3- yl)oxazole) and analogs selectively potentiate GABA_A receptors containing α2/3 subunits and have recently been shown to attenuate pain behaviors in several acute and chronic pain models in rodents. The present study was designed to ascertain whether KRM-II-81 and the structural analog MP-III-80 (3-ethyl-5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3-yl)-1,2,4-oxadiazole) would block chemotherapeutic agent paclitaxel-induced pain in male, C57BL/6 mice. Both compounds significantly inhibited pain behaviors evoked by cold and tactile stimulation in paclitaxel-treated mice as did the neuropathic pain drug gabapentin. Subchronic dosing for 22 days with KRM-II-81 and MP-III-80 demonstrated enduring analgesic efficacy without tolerance development, while the effects of gabapentin showed evidence of tolerance development. KRM-II-81 and MP-III-80 also decreased marble-burying behavior in this mouse strain as did the anxiolytic drug chlordiazepoxide. In contrast to KRM-II-81 and MP-III-80, chlordiazepoxide had motor-impairing effects at anxiolytic-like doses. The data add to the literature documenting that these selective potentiators of α2/3-containing GABA_A receptors are effective in a host of animal models used to detect novel analgesic drugs. The anxiolytic-like efficacy of these compounds fits well with the comorbidity of anxiety in patients with chronic pain and cancer.

Mediastinal herniation of the biliary tract leading to bile duct: obstruction following oesophagectomy

Surgical management of oesophageal and gastro-oesophageal junction malignancies is one of the most challenging situations confronting the surgeon. Attaining a complete circumferential resection margin of lower-third oesophageal and gastro-oesophageal junction locally advanced carcinomas requires en-bloc resection of the hiatus and all the peri-oesophageal tissue and pleura. This results in an increased risk of herniation of the abdominal organs through the enlarged hiatus, which carries significant risk of morbidity and mortality. The incidence of this complication is higher than has been reported. Surgical management of symptomatic hernias is the standard treatment while criteria for managing asymptomatic hernias are less clear. We report a rare case of a late mediastinal herniation of the pancreas and bile duct, leading to obstructive jaundice following oesophagectomy which was treated successfully in our unit.

Meta-analysis of the effect of bariatric surgery on physical function

BACKGROUND

Obesity leads to an impairment of physical function that limits the ability to perform basic physical activities affecting quality of life. Literature on the effect of bariatric surgery on physical function is confounding and generally of low quality.

METHODS

A comprehensive search was undertaken using MEDLINE, Scopus (including Embase), CENTRAL, PubMed, SPORTDiscus, Scirus and OpenGrey for published research and non-published studies to 31 March 2017. Studies employing objective measurement and self-reporting of physical function before and after bariatric surgery were included. The magnitude of experimental effect was calculated in terms of the standardized mean difference (MD), and confidence intervals were set at 95 per cent to reflect a significance level of 0·05.

RESULTS

Thirty studies including 1779 patients met the inclusion criteria. Physical function improved after bariatric surgery at 0-6 months (MD 0·90, 95 per cent c.i. 0·60 to 1·21; P < 0·001), more than 6 to 12 months (MD 1·06, 0·76 to 1·35; P < 0·001) and more than 12 to 36 months (MD 1·30, 1·07 to 1·52; P < 0·001). Objective assessment of physical function after bariatric surgery showed improvement at 0-6 months (MD 0·94, 0·57 to 1·32; P < 0·001), more than 6 to 12 months (MD 0·77, 0·15 to 1·40; P = 0·02) and more than 12 to 36 months (MD 1·04, 0·40 to 1·68; P = 0·001). Self-reported assessment of physical function showed similar improvements at 0-6 months (MD 0·80, 0·12 to 1·47; P = 0·02), more than 6 to 12 months (MD 1·42, 1·23 to 1·60; P < 0·001) and more than 12 to 36 months (MD 1·41, 1·20 to 1·61; P < 0·001) after a bariatric procedure.

CONCLUSION

Bariatric surgery improves physical function significantly within 6 months of the procedure and this effect persists over time to 36 months after surgery, whether measured objectively or by self-reporting.

Evaluation of deletion polymorphisms of glutathione S-transferase genes and colorectal cancer risk in ethnic Kashmiri population: A case-control study

AIM

Glutathione S.transferases. (GSTs) are known to play a pivotal role in the detoxification of potential carcinogens, and their gene variation may alter susceptibility to colorectal cancer. (CRC). The aim of the study was to evaluate the genetic association of GSTM1 and GSTT1 gene deletion/null polymorphism with disease susceptibility and risk development in CRC patients of ethnic Kashmiri population.

MATERIALS AND METHODS

Genotype frequencies of GSTM1 and GSTT1 gene deletion/null polymorphism were compared between 160 CRC patients and 200 healthy controls using polymerase chain reaction multiplex.

RESULTS

The frequency of GSTM1-null was found to be 76.2% in cases and 81.5% in controls and odds ratio. (OR) = 1.37 (95% confidence interval. [CI]: 0.82-2.28). Likewise, the GSTT1-null genotype was found in 75.5% of cases and 77.5% of controls and the OR = 1.14 (95% CI: 0.76-1.8). The overall association between the GSTM1-null and GSTT1-null polymorphism and the CRC cases was found to be insignificant (P < 0.05). However, individuals with double-null genotype (GSTM1-/GSTT1-) were found to have 3.5-fold increased risk for the development of CRC. Further, the risk genotype (null) of GSTT1 was found to be associated with tumor grade (P = 0.001) and GSTM1 (null) genotype was significantly associated with smoking status (P = 0.004), when compared to the (present) genotype in CRC cases.

CONCLUSION

Our results suggest that GSTM1 and GSTT1 gene deletion/null gene polymorphisms are not a key modulators of the risk of developing CRC in Kashmiri population.

Bifidobacterium longum BB536 alleviated upper respiratory illnesses and modulated gut microbiota profiles in Malaysian pre-school children

This 10-months randomised, double-blind, parallel and placebo-controlled study evaluated the effects of Bifidobacterium longum BB536 on diarrhoea and/or upper respiratory illnesses in 520 healthy Malaysian pre-school children aged 2-6 years old. The subjects randomly received a one-gram sachet containing either BB536 (5×109 cfu) or placebo daily. Data analysis was performed on 219 subjects who fully complied over 10-months (placebo n=110, BB536 n=109). While BB536 did not exert significant effects against diarrhoea in children, Poisson regression with generalised estimating equations model indicated significant intergroup difference in the mean number of times of respiratory illnesses over 10 months. The duration of sore throat was reduced by 46% (P=0.018), with marginal reduction for duration of fever (reduced by 27%, P=0.084), runny nose (reduced by 15%, P=0.087) and cough (reduced by 16%, P=0.087) as compared to the placebo. Principal coordinate analysis at genus level of the gut microbiota revealed significant differences between 0 and 10 months in the BB536 group (P<0.01) but not in placebo group (P>0.05). The abundance of the genus Faecalibacterium which is associated with anti-inflammatory and immuno-modulatory properties was significantly higher in the BB536 group (P<0.05) compared to the placebo group. Altogether, our present study illustrated the potential protective effects of BB536 against upper respiratory illnesses in pre-school Malaysian children, with gut microbiota modulating properties.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Fiber gene based molecular and biological characterization of hydropericardium-hepatitis syndrome associated avian adenoviruses

This study was designed to perform biological and molecular characterization of avian adenoviruses (AAVs) recovered from suspected cases of hydropericardium-hepatitis syndrome (HHS) in commercial poultry. Initially the samples were screened by Agar Gel Precipitation Test (AGPT) for the presence of AAVs followed by its confirmation and typing through polymerase chain reaction (PCR) focusing on already reported serotypes AAV-4, AAV-8 and AAV-10 elsewhere. These PCR-positive samples were further subjected to amplification of fiber gene, followed by conducting restriction fragment length polymorphism (RFLP) using restriction enzyme Alu. The selected isolates were further propagated through cell culture and pathogenic potential of selected isolates was determined by infecting chickens. In this study, out of a total 190 samples, 57.8% of suspected cases were found positive for AAV presence through AGPT while sub-type identification using PCR revealed 46.3% for these viruses belonging to AAV-4, 41.8% to AAV-8 and 11.8% showed co-infection of AAV-4 and AAV-8. AAV-10 was not detected in any of the tested samples. On the basis of RFLP pattern, AAV-4 isolates were further divided into four sub-groups (A-D) while AAV-8 isolates had identical RFLP pattern. To further evaluate the pathogenic potential of these sub-groups of AAV-4 isolates, specific pathogen free (SPF) chicks were challenged with selected isolates belonging to each of the sub-groups, resulting in variable pattern of pathogenicity. It is concluded that any variation in the fiber gene of AAV-4 isolates may affect its pathogenicity and eventually specificity of the vaccines used against such infections. Therefore, regular monitoring of the circulating AAV serotypes may be helpful in understanding the pathogenic potential of emerging AAVs, which may lead to development of more effective response strategies accordingly.

A randomised controlled trial of three aesthetic full-coronal restorations in primary maxillary teeth

AIM

This randomised clinical trial (RCT) compared the clinical outcomes of three aesthetic full-coronal restorations (composite strip crowns, pre-veneered stainless steel crowns (SSCs) and pre-fabricated primary zirconia crowns) in carious and traumatised primary maxillary incisors.

MATERIALS AND METHODS

One hundred and twenty nine teeth in 39 children aged between 3 to 5 years were included. Children were randomly assigned to one of three treatment groups using a permuted block randomisation technique with a total of 43 teeth in each group. After trainee calibration, restorations were placed and evaluated after 6 months. Outcomes evaluated were restoration failure, tooth wear of opposing teeth and gingival health.

RESULTS

The retention rate was highest for zirconia crowns (100%) followed by pre-veneered SSCs (95%). Strip crowns were the least retentive (78%). Zirconia crowns showed low grade abrasion in four opposing teeth. Teeth restored with resin composite and pre-veneered SSC showed an increase in mean gingival index score, while corresponding values decreased in zirconia crowns.

CONCLUSION

Resin composite strip crown is a highly sensitive technique leading to lower retention rate. Pre-veneered stainless steel crowns showed increased incidence of facial veneer fracture. Zirconia crowns are highly retentive and biocompatible but cause low grade of abrasion of their opposing natural dentition at the 6-month follow-up.

Peritonitis following a bariatric procedure in a young woman

A 22-year-old woman presented with generalised peritonitis from a gastric perforation due to erosion by an intragastric balloon inserted abroad 22 months previously in an attempt to help her lose weight. These balloons are of uncertain long-term benefit in obesity and should be removed after 6 months to avoid complications. This did not happen in this case; thus, leading to this life-threatening complication, which was treated with the removal of the balloon and omental patch repair of the perforation.

Role of routine oesophago-gastroduodenoscopy before cholecystectomy

INTRODUCTION

A proportion of patients do not get symptomatic relief after cholecystectomy because there is an overlap in the symptomology of biliary and gasroduodenal pathologies. In our unit all the patients are offered gastroscopy prior to Cholecystectomy. Aim of this study was to evaluate the efficacy of gastroscopy in all patients with upper abdominal pain irrespective of ultrasound findings.

MATERIAL AND METHODS

This retrospective study was carried out, between Jan 2001-Oct 2003. All the patients undergoing laparoscopic cholecystectomy by a single surgeon were studied. Group 1 (n = 61) were not endoscoped before the operation (Jan 2001-May 2002). Group 2 (n = 60) had routine endoscopy carried out before surgery (June 2002-October 2003). The results were entered in a database and analyzed.

RESULTS

Total of 240 laparoscopic cholecystectomies were carried out. Female to male ratio was 4:1. In Group 1, the recurrence or persistence of symptoms was 20/61 (32.78%) patients who were not scoped. In Group 2, all patients were scoped with positive findings in 35% of the patients. All were treated for the pathology and only 2(3.3%) had recurrence or persistence of symptoms.

CONCLUSION

The routine use of gastroscopy before laparoscopic cholecystectomy helps to reduce persistence of symptoms and is recommended.

Globule formation of a clay mineral and a rapid method for the treatment of liquid radioactive waste

A technique has been proposed for the grain formation of a naturally available clay mineral (inorganic sorbent). The clay mineral was processed to form the globules to ease the decontamination of low and intermediate levels of liquid radioactive wastes. The purpose of this study is to develop a new form of inorganic sorbing material in the form of beads for the treatment of liquid radioactive waste originating from different types of nuclear installations. This material in the form of spherical beads can also be used for the immobilization of secondary waste that results as a byproduct from processing of nuclear wastes. As it is a major radiotoxic nuclide present in the nuclear wastes, the sorption of cesium from the low level liquid radioactive waste has been described. The potential utilization of this porous clay as an inexpensive material for the final disposal of radioactive wastes has been suggested.

Vertebroplasty for vertebral compression fractures secondary to Cushing's syndrome induced by an ACTH-producing bronchial carcinoid tumour

Adrenocorticotropic hormone (ACTH)-producing bronchial carcinoid tumours are a rare cause of Cushing's syndrome. Cushing's syndrome is frequently complicated by osteoporosis, which results in an increased tendency for the development of vertebral compression fractures. Percutaneous vertebroplasty has been shown to be an effective treatment option in the setting of painful osteoporotic compression fractures refractory to conservative therapies. We report a case where vertebroplasty was performed on a 36-year-old woman with osteoporosis and compression fractures secondary to hypercorticolism. A bronchial carcinoid tumour was found to be the source of excess ACTH production. Three-level percutaneous vertebroplasty resulted in a marked improvement in pain.

Detailed Biochemical Characterization of Human Placental Cystatin (HPC)

A low molecular weight thiol protease inhibitor (12,500) purified from human placenta has been characterized in detail. Human placental cystatin (HPC) was found to be stable in the pH range 3.0-9.0 and temperature stability was between 40 and 100 degrees C. It does not have any disulphide groups and carbohydrate content. There was no cross-reaction between anti-HPC serum and other purified cystatins like HMW kininogens isolated from sheep plasma and phytocystatins isolated from Phaseolus mungo. The kinetics of inhibition of HPC was studied with ficin and bromelain and the comparison was made with our already reported results with papain. The respective K(i) values obtained for ficin and bromelain are 8.4 x 10(-8) M and 9.5 x 10(-8) M, respectively, whereas the value for papain was 5.5 x 10(-8) M. The values of association constants (K(ass)) for ficin and bromelain were 2.9 x 10(3) and 8.6 x 10(2) M(-1) s(-1), respectively, however, the value for papain was 3.4 x 10(4) M(-1) s(-1), the respective dissociation constant values for ficin and bromelain were 2.6 x 10(-5) and 2.1 x 10(-5) s(-1), respectively, and the value obtained for papain was 2.3 x 10(-5) s(-1). These kinetic parameters taken together along with t(1/2) values and IC(50) values imply that HPC binds more effectively to papain, then ficin and least with bromelain. Far-UV-CD analysis shows that HPC has 21.08% alpha-helical structure and significant amount of beta structure. Near-UV-CD spectra of HPC show positive peak at 280 nm indicating significant amount of tertiary interactions. The partial amino acid sequence analysis shows that HPC has highest sequence homology with chicken cystatin and Gly residue is present at position 11 rather than at conserved position 9, which has also been reported for human stefin A structure. The hydropathy plot of 1-30 amino acid residues shows that most amino acids of this stretch are present in the hydrophobic core of the protein. Owing to low molecular weight, absence of disulphide bonds and carbohydrate content HPC can be placed in type I cystatin family with some resemblance to chicken cystatin as shown by CD studies and amino acid sequence analysis.

Effect of polyols and salts on the acid-induced state of human placental cystatin

Polyols (glycerol and sorbitol) and salts (magnesium sulfate, sodium sulfate, and magnesium chloride) have been used to study the refolding of the acid-induced state of human placental cystatin (HPC), which is a low molecular weight (12,500 daltons) thiol proteinase inhibitor, in terms of CD spectroscopy, binding of hydrophobic dye 1-anilinonaphthalene-8-sulfonic acid (ANS), and intrinsic fluorescence measurements. The helical content of acid-denatured HPC increased with increase in glycerol concentration (0-80%). At 80% glycerol concentration, the secondary structural features observed in the far UV-CD region are similar to those of the native state (pH 6.0). The intrinsic fluorescence and near UV-CD studies showed that this 80% glycerol-induced state has a significant amount of tertiary structure with decreased ANS binding compared to the acid-denatured state. It was found that glycerol is more effective in stabilizing the acid-denatured state of HPC as compared to sorbitol. Among salts the stability effect was more for MgCl(2) (used up to concentration of 3 M) compared to MgSO(4) and Na(2)SO(4) (used up to the concentration of 1.5 M due to restricted solubility of HPC at higher sulfate salt concentrations) as determined by CD studies and fluorescence measurements, which showed secondary and tertiary structural resemblance of this MgCl(2)-induced state close to native state and showed overall spectral features in between the native state and the acid-denatured state. This MgCl(2) (3 M)-induced state showed decreased ANS fluorescence as compared to the acid-denatured state but more than that of the native state. The results taken together suggest that the acid-denatured state of HPC in the presence of 80% glycerol or 3 M MgCl(2) has a conformation in between that of the native state (pH 6.0) and the acid-induced state at pH 2.0.

Studies on low molecular mass phytocystatins purified from Phaseolus mungo (Urd)

In the present study two phytocystatins (thiol protease inhibitors) have been isolated and purified to homogeneity from Phaseolus mungo by a simple two-step procedure using ammonium sulfate fractionation and gel filtration on Sephacryl-100 HR. The latter procedure yielded two peaks of the inhibitors (PMC I and PMC II). The pH optimum of both phytocystatins was pH 7.0; the temperature optima for PMC I and PMC II were 65 and 70 degrees C, respectively. The molecular masses of the purified phytocystatins were 19 and 17 kD, respectively, as determined by SDS-PAGE and mass spectrometry. Antibodies raised against the purified cystatins gave a single precipitin line in Ouchterlony double immunodiffusion. Kinetics of inhibition showed that PMC I and PMC II strongly inhibit papain and ficin but not trypsin and chymotrypsin. Binding stoichiometry of PMC I and PMC II with both papain and ficin was 1 : 2. The effect of urea on PMC I and PMC II was analyzed by fluorescence and circular dichroism spectroscopy. The CD results suggest an unfolding of PMC I and PMC II accompanying a decrease in the amount of extended (hydrated) coil structure and an increase in sheet-like structure. FTIR results show that PMC I is structurally similar to PMC II. Hydrophobic interactions are observed over a long time scale (5-150 min). Furthermore, fluorescence spectroscopy results were found to be in accordance with CD results, by showing quenching of fluorescence intensity of PMC I and PMC II, although to different extents, due to perturbations of the environment of aromatic residues in the protein. Both cystatins showed strong inhibitory activity against Escherichia coli and Staphylococcus aureus.

Complementary studies of the gastrointestinal safety of the cyclo-oxygenase-2-selective inhibitor etoricoxib

BACKGROUND

Cyclo-oxygenase-2-selective non-steroidal anti-inflammatory drugs are intended to preserve cyclo-oxygenase-1-mediated gastroprotection and platelet function, whilst inhibiting cyclo-oxygenase-2-mediated inflammation.

AIM

To assess the gastrointestinal safety of the cyclo-oxygenase-2-selective inhibitor etoricoxib vs. non-selective non-steroidal anti-inflammatory drugs.

METHODS

Two randomized, double-blind, placebo- and active-controlled studies were performed: (i) daily faecal red blood cell loss was measured in 62 subjects receiving etoricoxib (120 mg once daily), ibuprofen (800 mg t.d.s.) or placebo for 28 days; (ii) the incidence of endoscopically detectable gastric/duodenal ulcers was determined in 742 osteoarthritis or rheumatoid arthritis patients receiving etoricoxib (120 mg once daily), naproxen (500 mg b.d.) or placebo over 12 weeks.

RESULTS

In the first study, the between-treatment ratio of faecal blood loss for etoricoxib vs. placebo (1.06) was not significantly different from unity; however, the ratios for ibuprofen vs. placebo (3.26) and etoricoxib (3.08) were significantly greater than unity (P < 0.001). In the second study, the incidence of ulcers of > or = 3 mm with naproxen (25.3%) was significantly higher than that with etoricoxib (7.4%) or placebo (1.4%; P < 0.001); the results were similar for ulcers of > or = 5 mm.

CONCLUSIONS

The reduced toxicity of etoricoxib (less faecal blood loss and fewer endoscopically detectable lesions) suggests that use of this drug will may be associated with a reduced incidence of gastrointestinal perforations, ulcers and bleeds.

Changing face of adult coeliac disease: experience of a single university hospital in South Yorkshire

OBJECTIVE

To determine the incidence and presenting features of adult coeliac disease in a single university hospital in South Yorkshire.

DESIGN

A retrospective case finding study. Data were obtained from pathology and immunology databases, clinical notes, dietetic records, and patient questionnaires.

SETTING

Royal Hallamshire Hospital in South Yorkshire, England.

PARTICIPANTS

All recorded cases of coeliac disease.

MAIN OUTCOME MEASURES

Crude annual incidence rates for coeliac disease was obtained. The numbers of coeliac antibody profiles requested per year from the Royal Hallamshire Hospital were ascertained. Age at diagnosis, sex, year of diagnosis, presenting symptoms, associated conditions, and delay in diagnosis was documented. In addition the specialty of the clinician who made the diagnosis was noted.

RESULTS

There were 264 cases in total (male n=86, ratio 1:2). Mean age at diagnosis was 44.9 years (range 1-82, median 44.5). A trend was observed from 1990 to 2000 inclusive, of an annual increase in the incidence of coeliac disease. There has been a coincidental increase in the measurement of associated antibodies. Although 28.4% of patients presented with gastrointestinal symptoms, 20.1% had iron deficiency anaemia. The ratio of typical to atypical symptoms was 1:2.5. (single sample test of proportions p<0.001). The diagnosis was made by a gastroenterologist in only 52.7% of cases. The median duration of symptoms before the diagnosis of coeliac disease was 4.9 years (range 0.25-16 years).

CONCLUSION

Coeliac disease is now presenting more commonly without gastrointestinal symptoms and often to specialties other than gastroenterology. Although more cases are diagnosed, this may be a reflection of increasing recognition rather than a true increase in incidence.

An alternative approach to the management dilemma of the mildly dyskaryotic smear based on audit of outcome

We describe a study which takes an alternative approach to the management dilemma of the mildly dyskaryotic cervical smear. Two hundred and fifty women with a smear showing mild dyskaryosis were studied by auditing the clinical outcome as well as the cost. The cost of providing the colposcopy services during the index year was approximately pounds sterling 70000 for an average size district general Hospital. The proportion of women managed by the current guidelines and avoiding colposcopy after a first mildly dyskaryotic smear was only 30%. The majority of patients will eventually have colposcopy despite a policy of cytological surveillance. The alternative approach, to offer colposcopy immediately after the first mildly dyskaryotic smear, would result in a small increase in cost for our unit, equivalent to one extra colposcopy patient per week.

Mental health team leadership and consumers satisfaction and quality of life

OBJECTIVE

The purpose of this study was to determine the association between leadership styles of leaders of mental health treatment teams and consumers' ratings of satisfaction with the program and their quality of life.

METHODS

A multifactor model has distinguished three factors relevant to leadership of mental health teams: transformational leadership, in which a leader's primary goal is to lead the team to evolving better programs; transactional leadership, in which the leader strives to maintain effective programs through feedback and reinforcement; and laissez-faire leadership, an ineffective, hands-off leadership style. Research has shown transformational leadership to be positively associated with measures of the team's functioning, but the effects of leadership style on consumers is not well known. A total of 143 leaders and 473 subordinates from 31 clinical teams rated the leadership style of the team leader. In addition, 184 consumers served by these teams rated their satisfaction with the treatment program and their quality of life.

RESULTS

Consumers' satisfaction and quality of life were inversely associated with laissez-faire approaches to leadership and positively associated with both transformational and transactional leadership. Moreover, leaders' and subordinates' ratings of team leadership accounted for independent variance in satisfaction ratings-up to 40 percent of the total variance.

CONCLUSIONS

Leadership seems to be an important variable for understanding a team's impact on its consumers.