Evaluation status of current and emerging minimally invasive robotic surgical platforms

BACKGROUND

The rapid adoption of robotics within minimally invasive surgical specialties has also seen an explosion of new technology including multi- and single port, natural orifice transluminal endoscopic surgery (NOTES), endoluminal and "on-demand" platforms. This review aims to evaluate the validation status of current and emerging MIS robotic platforms, using the IDEAL Framework.

METHODS

A scoping review exploring robotic minimally invasive surgical devices, technology and systems in use or being developed was performed, including general surgery, gynaecology, urology and cardiothoracics. Systems operating purely outside the abdomen or thorax and endoluminal or natural orifice platforms were excluded. PubMed, Google Scholar, journal reports and information from the public domain were collected. Each company was approached via email for a virtual interview to discover more about the systems and to quality check data. The IDEAL Framework is an internationally accepted tool to evaluate novel surgical technology, consisting of four stages: idea, development/exploration, assessment, and surveillance. An IDEAL stage, synonymous with validation status in this review, was assigned by reviewing the published literature.

RESULTS

21 companies with 23 different robotic platforms were identified for data collection, 13 with national and/or international regulatory approval. Of the 17 multiport systems, 1 is fully evaluated at stage 4, 2 are stage 3, 6 stage 2b, 2 at stage 2a, 2 stage 1, and 4 at the pre-IDEAL stage 0. Of the 6 single-port systems none have been fully evaluated with 1 at stage 3, 3 at stage 1 and 2 at stage 0.

CONCLUSIONS

The majority of existing robotic platforms are currently at the preclinical to developmental and exploratory stage of evaluation. Using the IDEAL framework will ensure that emerging robotic platforms are fully evaluated with long-term data, to inform the surgical workforce and ensure patient safety.

Assessing the Effectiveness of Clinical Skills Laboratory and Traditional Lecture in Teaching Basic Life Support and Performance Evaluation According to Different Domains of Revised Bloom's Taxonomy

Sudden cardiac arrest out-side hospital is serious global concern. If non-medical people are taught to initiate the basic life support (BLS) training with cardiopulmonary resuscitation (CPR) then the mortality could be reduced significantly. This was a non-randomized controlled study to evaluate clinical skills laboratory (CSL) as teaching tool for basic life support (BLS) training in comparison to traditional lecture. Sample size was 68 and performed in Sylhet Women's Medical College from July 2022 to September 2022. All the participants were third year nursing students. They were enrolled in to two groups. Group-A were taught BLS by clinical skills laboratory (CSL) and Group-B were taught by traditional lecture (TL). At the end of the teaching all of them were tested by a vetted multiple choice question (MCQ) set. The questions were set according the 5 levels of revised Blood's taxonomy. Mean score of Group-A (CSL) were higher the TL group (p=0.0003). Among the revised Bloom's taxonomy understand, apply and evaluate domains were significantly better taught (p<0.05) by CSL. The sensitivity of CSL was 0.559 in comparison to TL for BLS training. In the modern medical education teaching and assessment should be focused on the higher levels of learning taxonomy. Introducing CSL in medical education could boost up the psychomotor and cognition both in the medical education.

Estimation of a cut-off value for immature platelet fraction (IPF) in predicting platelet recovery in dengue patients with thrombocytopenia

INTRODUCTION

Thrombocytopenia is a common complication in dengue that sometimes necessitates platelet transfusion. Immature platelet fraction (IPF) measures immature platelets that indirectly reflect thrombopoiesis and is helpful in predicting platelet recovery.

OBJECTIVES

This study aimed to evaluate the role of IPF% and identify its cut-off value in predicting platelet recovery in dengue patients with thrombocytopenia.

MATERIALS AND METHODS

Serial platelet count and IPF results were obtained from fifty-four confirmed dengue patients with platelet count <50x109 /L. Median peak IPF% and number of patients with platelet recovery were determined. Receiver operating characteristic (ROC) curve is generated to identify the IPF% cut-off value to predict platelet recovery.

RESULTS

Median peak IPF% among dengue patients was 12.15% with 83.3% of them achieving platelet recovery after reaching the peak IPF%. There was a significant difference between median IPF% on day one of admission with peak IPF% among dengue patients. ROC curve analysis showed IFP% of 10.55% can be used to predict platelet recovery with a sensitivity of 69% and a specificity of 67%.

CONCLUSION

IPF% is a reliable and useful parameter in predicting platelet recovery in dengue patients. This would assist the clinician in managing dengue patients especially those with severe thrombocytopenia without giving unnecessary platelet transfusion.

Effect of Cardiopulmonary Bypass on Blood and Coagulation Profile in Patients Undergoing Cardiac Surgery

This study was carried out in the department of cardiac surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2014 to April 2016. This study aims to evaluate the inadvertent effect of cardiopulmonary bypass on complete blood count and coagulation profile. This study was also compared the hemostatic parameters between patients undergoing elective cardiac surgery with CPB and without CPB. A total of 55 patients were included in this study. Among them 20 patients (Group A) were selected for elective cardiac surgery without cardiopulmonary bypass (CPB), 20 patients (Group B) with cardiopulmonary bypass time less than 90 minutes and 15 patients (Group C) were included with cardiopulmonary bypass time either 90 minutes or more. The mean age were 51.5±4.7 years ranging from 40-57 years in Group A, 33.2±10.2 years ranging from 18-50 years in Group B and 34.2±11.4 years ranging from 18-57 years in Group C. The difference of age was statistically significant (p<0.05) among three groups. The difference of post-operative mean hemoglobin and RBC value, WBC and Platelet count on arrival at the intensive care unit, at 48 hours and at 7 days after surgery were statistically significant (p<0.05) in the three groups. However, on arrival at Intensive Care Unit, after 48 hours and at 7 days after surgery, the change of coagulation profile like mean fibrinogen level, bleeding time, clotting time and prothrombin time were statistically significant (p<0.05) among the groups. Patient with long cardiopulmonary bypass time had shown blood and coagulation profile abnormality and it can be minimized if we can curtail the bypass time.

Biodiversity, distributions and isolation of microplastics pollution in finfish species in the Panjkora River at Lower and Upper Dir districts of Khyber Pakhtunkhwa province of Pakistan

The basic aim of this study was aimed to determine the ichthyofaunal diversity of River Panjkora in both upper and lower Dir districts in Khyber Pakhtunkhwa province of Pakistan.Fish samples were collected by using fishnets from March to September 2020. A total of 724 specimens were collected and classified into 5 families, 14 genera, and 18 species. The overall results revealed that most fish fauna of river Panjkora contains 8 species of family Cyprinidae (56.49%) followed by 4 species of Nemacheilidae (24.44%), 2 species of Channidae (10.63%), and Sisoridae (7.04%), and 1 species of Mastacembelidae (1.38%), respectively. Among all kinds of fish species, Schizothorax plagiostomus (16.57%) was highly dominated and followed by Carassius auratus (11.87%) and Racoma labiata (9.66%) and were reported as highly abundant, especially during April, May, and June. The least abundant species were Glyptothorax punjabensis, Glyptothorax sufii, and Mastacembelus armatus, that constituting 2.48%, 2.20%, and 1.38% of the total fish samples. The Overall Simpson's diversity (1-D= 0.919) and Simpson's Reciprocal index values (1/D= 12.3876), and Shannon's index (H= 2.68) were indicating that river Panjkora contains a quite rich and diverse group of fish species. The highest microplastics observed in site 7 compared to other study area. Conservation steps should be taken as a top priority to protect and conserve the marine environment and natural heritage from further loss, extinction and stop or minimize losses incurred through irresponsible fishery practices.

639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation

Background

Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE.

Case Summary

A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely.

Conclusions

RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.

Prevalence of rhabdochoniasis in snow trout of river Swat and river Panjkora, Khyber Pakhtunkhwa province, Pakistan

This research was aimed to explore the helminth parasitic diseases in Schizothorax plagiostomus (the snow trout) from river Swat and river Panjkora, Pakistan. Collection of 360 fish specimens have done from the lower, middle and upper reaches of both the rivers through gill nets, cast nets, dragon nets and hooks. All the samples were examined in the University of Malakand, Zoology Department for helminth parasites during the months from January 2015 to December 2016. Of the total examined fish samples 21.9% (n=79) were infected with Rhabdochona spp including 17.7% (n=32/180) in river Swat and 26.6% (n=47/180) in river Panjkora. Highest month-wise prevalence (p=0.09878,p<0.05) was reported in May (30%), then by February and October each (26.6%) while the lowest during August (13.3%). Highest prevalence (p=0.9723, p<0.05) was reported in summer season (26.6%), while lowest in the winter season (20%). Adults were highly infected (p=< 0.0001) in prevalence (63.7%) followed by sub-adults (13.2%) while no infection was found in juvenile specimens. Females fish samples had higher (p=0.0277, p>0.05) prevalence (28.8%) than males (16.6%). Fishes of the lower reaches had highest (p=0.0029, P>0.05) prevalence (31.7%) followed by middle reaches (16.5%) while the lowest prevalence was observed in samples of fish collected from upper reaches (9.87%). Present study address that Rhabdochona spp in the intestine of snow trout has a long term relationship and call as a natural infection in cyprinids and zoonotic risk to human.

Occupancy detection in non-residential buildings – A survey and novel privacy preserved occupancy monitoring solution

Buildings use approximately 40% of global energy and are responsible for almost a third of the worldwide greenhouse gas emissions. They also utilise about 60% of the world’s electricity. In the last decade, stringent building regulations have led to significant improvements in the quality of the thermal characteristics of many building envelopes. However, similar considerations have not been paid to the number and activities of occupants in a building, which play an increasingly important role in energy consumption, optimisation processes, and indoor air quality. More than 50% of the energy consumption could be saved in Demand Controlled Ventilation (DCV) if accurate information about the number of occupants is readily available (Mysen et al., 2005). But due to privacy concerns, designing a precise occupancy sensing/counting system is a highly challenging task. While several studies count the number of occupants in rooms/zones for the optimisation of energy consumption, insufficient information is available on the comparison, analysis and pros and cons of these occupancy estimation techniques. This paper provides a review of occupancy measurement techniques and also discusses research trends and challenges. Additionally, a novel privacy preserved occupancy monitoring solution is also proposed in this paper. Security analyses of the proposed scheme reveal that the new occupancy monitoring system is privacy preserved compared to other traditional schemes.

Using RT-PCR and glutathione level to study the effect of follicular fluid on in vitro maturation and gene expression of sheep oocytes

The aim of this study is to evaluate the effect of sheep follicular fluid (SFF) supplementation of the in vitro maturation (IVM) media of sheep oocytes on the resumption of meiosis, glutathione (GSH) level, and expression of apoptosis (Bax, Bcl-2) as well as heat shock protein beta-1 (HSPB1) genes. Sheep ovaries were collected from the central slaughterhouse of Riyadh city, KSA. Oocytes were aspirated from 3 to 8 mm follicles. Sheep oocytes were cultured in maturation medium with different concentrations of sheep follicular fluid: 0% (control), 10%, 20% and 40% for 24 h. The results indicated that the maturation rate of oocytes was significantly (p ≤ .05) decreased in 40% SFF (36.87%) versus the control (61.3%), 10% SFF (63.95%) and 20% SFF (64.08%). The supplementation of the IVM medium with 10% SFF induced an intra-oocyte GSH concentration that was significantly higher than in sheep oocytes cultured with 20% and 40% SFF and similar to the GSH content in oocytes cultured without SFF. Real-time polymerase chain reaction analysis of gene expression revealed no significant differences in the Bax and HSPB1 genes between the control and 10% SFF, whereas they were significantly higher in 40% FF (p ≤ .05) compared to the control. The expression of Bax:Bcl-2 was significantly higher in 20% and 40% SFF compared to the control group. In conclusion, the addition of SFF to the IVM culture of sheep oocytes is recommended to support nuclear maturation and increase oocyte competence.

Facial expression recognition as a candidate marker for autism spectrum disorder: how frequent and severe are deficits?

Background

Impairments in social communication are a core feature of Autism Spectrum Disorder (ASD). Because the ability to infer other people’s emotions from their facial expressions is critical for many aspects of social communication, deficits in expression recognition are a plausible candidate marker for ASD. However, previous studies on facial expression recognition produced mixed results, which may be due to differences in the sensitivity of the many tests used and/or the heterogeneity among individuals with ASD. To ascertain whether expression recognition may serve as a diagnostic marker (which distinguishes people with ASD from a comparison group) or a stratification marker (which helps to divide ASD into more homogeneous subgroups), a crucial first step is to move beyond identification of mean group differences and to better understand the frequency and severity of impairments.

Methods

This study tested 46 individuals with ASD and 52 age- and IQ-matched typically developing (TD) participants on the Films Expression Task, which combines three key features of real-life expression recognition: naturalistic facial expressions, a broad range of simple and complex emotions, and short presentation time. Test-retest reliability was assessed in 28 individuals who did not participate in the main study and revealed acceptable reliability (ICC r = .74).

Results

Case-control comparisons showed highly significant mean group differences for accuracy (p = 1.1 × 10^− 10), with an effect size (Cohen’s d = 1.6), more than twice as large as the mean effect size reported in a previous meta-analysis (Uljarevic and Hamilton, 2012, J Autism Dev Disord). The ASD group also had significantly increased mean reaction times overall (p = .00015, d = .83) and on correct trials (p = .0002, d = .78). However, whereas 63% of people with ASD showed severe deficits (they performed below two standard deviations of the TD mean, a small subgroup (15.3%) performed normally (within one standard deviation of the mean).

Conclusion

These findings indicate that the majority of people with ASD have severe expression recognition deficits and that the Films Expression Test is a sensitive task for biomarker research in ASD. Future work is needed to establish whether ASD subgroups with and without expression recognition deficits differ from one another in terms of their symptom profile or neurobiological underpinnings.

Electronic supplementary material

The online version of this article (10.1186/s13229-018-0187-7) contains supplementary material, which is available to authorized users.

(μ2-Adipato-κ4O,O':O'',O''')bis-[aqua-(benzene-1,2-di-amine-κ2N,N')-chlorido-cadmium]: crystal structure and Hirshfeld surface analysis

In the centrosymmetric binuclear title compound, the Cd^II atoms are linked by a μ₂-adipate dianion; the distorted octa­hedral geometry of the metal ion is defined by a ClN₂O₃ donor set.

The full mol­ecule of the binuclear title compound, [Cd₂Cl₂(C₆H₈O₄)(C₆H₈N₂)₂(H₂O)₂], is generated by the application of a centre of inversion located at the middle of the central CH₂—CH₂ bond of the adipate dianion; the latter chelates a Cd^II atom at each end. Along with two carboxyl­ate-O atoms, the Cd^II ion is coordinated by the two N atoms of the chelating benzene-1,2-di­amine ligand, a Cl⁻ anion and an aqua ligand to define a distorted octa­hedral CdClN₂O₃ coordination geometry with the monodentate ligands being mutually cis. The disparity in the Cd—N bond lengths is related to the relative trans effect exerted by the Cd—O bonds formed by the carboxyl­ate-O and aqua-O atoms. The packing features water-O—H⋯O(carboxyl­ate) and benzene-1,2-di­amine-N—H⋯Cl hydrogen bonds, leading to layers that stack along the a-axis direction. The lack of directional inter­actions between the layers is confirmed by a Hirshfeld surface analysis.

Copper doping enhanced the oxidative stress-mediated cytotoxicity of TiO2 nanoparticles in A549 cells

Physicochemical properties of titanium dioxide nanoparticles (TiO₂ NPs) can be tuned by doping with metals or nonmetals. Copper (Cu) doping improved the photocatalytic behavior of TiO₂ NPs that can be applied in various fields such as environmental remediation and nanomedicine. However, interaction of Cu-doped TiO₂ NPs with human cells is scarce. This study was designed to explore the role of Cu doping in cytotoxic response of TiO₂ NPs in human lung epithelial (A549) cells. Characterization data demonstrated the presence of both TiO₂ and Cu in Cu-doped TiO₂ NPs with high-quality lattice fringes without any distortion. The size of Cu-doped TiO₂ NPs (24 nm) was lower than pure TiO₂ NPs (30 nm). Biological results showed that both pure and Cu-doped TiO₂ NPs induced cytotoxicity and oxidative stress in a dose-dependent manner. Low mitochondrial membrane potential and higher caspase-3 enzyme (apoptotic markers) activity were also observed in A549 cells exposed to pure and Cu-doped TiO₂ NPs. We further observed that cytotoxicity caused by Cu-doped TiO₂ NPs was higher than pure TiO₂ NPs. Moreover, antioxidant N-acetyl cysteine effectively prevented the reactive oxygen species generation, glutathione depletion, and cell viability reduction caused by Cu-doped TiO₂ NPs. This is the first report showing that Cu-doped TiO₂ NPs induced cytotoxicity and oxidative stress in A549 cells. This study warranted further research to explore the role of Cu doping in toxicity mechanisms of TiO₂ NPs.

The pattern of invasive lobular carcinoma in the patients diagnosed with breast cancer from Balochistan

INTRODUCTION

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for 5%-15% of all the breast cancer cases. The present study was performed on 171 breast cancer patients from Balochistan registered in CENAR (Center for Nuclear Medicine and Radiotherapy), Quetta.

MATERIALS AND METHODS

Written consent was obtained from the patients. The history of the disease was taken from the patients, and the patients' enrollment files were retrieved.

RESULTS

Of the 171 patients, 5 (2.96%) were diagnosed with ILC with tumor Grade II, and stage of the cancer reported was Grade III in all the 5 patients affected with ILC.

CONCLUSION

ILC is the second most common type of breast cancer diagnosed with comparatively lower grade but almost reported infiltrating.

Improved functional assessment of osteoarthritic knee joint after chondrogenically induced cell treatment

OBJECTIVES

Our previous studies on osteoarthritis (OA) revealed positive outcome after chondrogenically induced cells treatment. Presently, the functional improvements of these treated OA knee joints were quantified followed by evaluation of the mechanical properties of the engineered cartilages.

METHODS

Baseline electromyogram (EMGs) were conducted at week 0 (pre-OA), on the locomotory muscles of nine un-castrated male sheep (Siamese long tail cross) divided into controls, adipose-derived stem cells (ADSCs) and bone marrow stem cells (BMSCs), before OA inductions. Subsequent recordings were performed at week 7 and week 31 which were post-OA and post-treatments. Afterwards, the compression tests of the regenerated cartilage were performed.

RESULTS

Post-treatment EMG analysis revealed that the control sheep retained significant reductions in amplitudes at the right medial gluteus, vastus lateralis and bicep femoris, whereas BMSCs and ADSCs samples had no further significant reductions (P < 0.05). Grossly and histologically, the treated knee joints demonstrated the presence of regenerated neo cartilages evidenced by the fluorescence of PKH26 tracker. Based on the International Cartilage Repair Society scores (ICRS), they had significantly lower grades than the controls (P < 0.05). The compression moduli of the native cartilages and the engineered cartilages differed significantly at the tibia plateau, patella femoral groove and the patella; whereas at the medial femoral condyle, they had similar moduli of 0.69 MPa and 0.40-0.64 MPa respectively. Their compression strengths at all four regions were within ±10 MPa.

CONCLUSION

The tissue engineered cartilages provided evidence of functional recoveries associated to the structural regenerations, and their mechanical properties were comparable with the native cartilage.

Structural modeling and analysis of dengue-mediated inhibition of interferon signaling pathway

Dengue virus (DENV) belongs to the family Flaviviridae and can cause major health problems worldwide, including dengue fever and dengue shock syndrome. DENV replicon in human cells inhibits interferon α and β with the help of its non-structural proteins. Non-structural protein 5 (NS5) of DENV is responsible for the proteasome-mediated degradation of signal transducer and activator of transcription (STAT) 2 protein, which has been implicated in the development of resistance against interferon-mediated antiviral effect. This degradation of STAT2 primarily occurs with the help of E3 ubiquitin ligases. Seven in absentia homologue (SIAH) 2 is a host protein that can mediate the ubiquitination of proteins and is known for its interaction with NS5. In this study, comprehensive computational analysis was performed to characterize the protein-protein interactions between NS5, SIAH2, and STAT2 to gain insight into the residues and sites of interaction between these proteins. The objective of the study was to structurally characterize the NS5-STAT2, SIAH2-STAT2, and NS5-SIAH2 interactions along with the determination of the possible reaction pattern for the degradation of STAT2. Docking and physicochemical studies indicated that DENV NS5 may first interact with the host SIAH2, which can then proceed towards binding with STAT2 from the side of SIAH2. These implications are reported for the first time and require validation by wet-lab studies.

A cross sectional study of p504s, CD133, and Twist expression in the esophageal metaplasia dysplasia adenocarcinoma sequence

The incidence of esophageal adenocarcinoma has increased dramatically over recent years and Barrett's esophagus is considered the most established risk factor for its development. Endoscopic surveillance of Barrett's esophagus is therefore recommended but hinges on histological interpretation of randomly taken biopsies which is poorly reproducible. The use of biomarkers presents an opportunity to improve our ability to risk-stratify these patients.We examined three biomarkers namely p504s, CD133, and Twist in the setting of Barrett's esophagus, low-grade dysplasia, and esophageal adenocarcinoma to evaluate differential expression between benign, dysplastic, and malignant Barrett's tissue in an exploratory cross-sectional study. Twenty-five cases each of Barrett's esophagus, low-grade dysplasia, and esophageal adenocarcinoma were included along-with 25 cases of esophagectomy resections for Barrett's adenocarcinoma. The biomarkers were immunostained on automated Ventana(®) immunostainer. The biopsies were assessed for biomarker expression by two independent observers. Granular cytoplasmic staining of p504s was observed in dysplastic Barrett's biopsies and esophageal adenocarcinoma but not in Barrett's esophagus. Apical and membranous CD133 expression was also observed in dysplastic Barrett's and esophageal adenocarcinoma. Nuclear Twist expression was seen predominantly in stromal cells. There was increased p504s expression in dysplastic Barrett's esophagus and esophageal adenocarcinoma compared with controls. CD133 expression was detected for the first time in esophageal adenocarcinoma and dysplastic Barrett's esophagus. Twist expression was not convincing enough to be labeled as Barrett's biomarker. p504s and CD133 have the potential to differentiate benign from malignant Barrett's tissue in this exploratory study. Their validity should be established in prospective longitudinal studies.

Spilled gallstones during laparoscopic cholecystectomy

INTRODUCTION

Incidental gallbladder cancer is found in 0.6-2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery.

CASE HISTORY

A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour.

CONCLUSIONS

This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.

Identification of a novel mutation (p.Ile198Thr) in gene TYR in a Pakistani family with nonsyndromic oculocutaneous albinism

The TYR gene (MIM #6069333) is located at position 11q14.3 on the human chromosome, and encodes tyrosinase, which is expressed in melanocytes and controls the biosynthesis of melanin. Most TYR mutations eliminate the activity of tyrosinase, preventing melanocytes from producing any melanin throughout life. People with this form of albinism have white hair, light-coloured eyes and very pale skin. Some mutations in TYR reduce but do not completely eliminate tyrosinase activity, and allow some melanin to be produced. We report a Pakistani family with four members affected by oculocutaneous albinism (OCA). Blood samples were collected from all affected individuals, normal siblings and their parents. Genomic DNA was extracted, and sequence analysis of all the coding exons and adjacent intronic sequences of TYR was performed, which identified a novel missense substitution (p.Ile198Thr). Sequencing of TYR in 90 unrelated healthy individuals showed no sequence variant at this location. Our study expands the mutational spectrum of OCA1.

Flashing light as growth stimulant in cultivation of green microalgae, Chlorella sp. utilizing airlift photobioreactor

One of the main limitations of productivity in photobioreactor is the inefficient conversion of the available light into biomass. Photoautotrophic cells such as microalgae only absorb a small fraction of supplied illumination due to limitation of its photosystem's (PS) absorbing rate. However, phenomenon of Flashing Light Effect (FLE) allows microalgae to utilize strong light exceptionally through intermittent exposure. Exposure of strong light at correct frequency of light and dark photoperiod would allow two pigment-protein complexes, PSI and PSII to be at the equilibrium mid-point potential to allow efficient light conversion. Narrow range of optimum frequency is crucial since overexposure to strong light would injured photosynthetic apparatus whereas longer dark period would contributed to loss of biomass due to triacylglycerol metabolism. The behaviour of microalgae towards various illumination conditions of FLE was determined at batch Photobioreactor (PBR) by varying the aeration flow rate: 16.94, 33.14 and 49.28 mL sec(-1) which yield, respectively the light exposure time of 3.99, 1.71 and 1.1 seconds per cycle. Maximum cell density in FLE-PBR was significantly higher at the exponential phase as compared to the continuously illuminated culture (p = 5.62 x 10(-5), a = 0.05) under the flow rate of 25.07 mL sec(-1). Maximum cell density yield of FLE-PBR and continuously illuminated PBR was, respectively 3.1125 x 10(7) and 2.947 x 10(7) cells mL(-1). Utilization of FLE as an innovative solution to increase the efficiency of microalgae to convert light into chemical energy would revolutionize the microalgae culture, reduce the time for cultivation and produce higher maximum biomass density.

Rotenone-induced oxidative stress and apoptosis in human liver HepG2 cells

Rotenone, a commonly used pesticide, is well documented to induce selective degeneration in dopaminergic neurons and motor dysfunction. Such rotenone-induced neurodegenration has been primarily suggested through mitochondria-mediated apoptosis and reactive oxygen species (ROS) generation. But the status of rotenone induced changes in liver, the major metabolic site is poorly investigated. Thus, the present investigation was aimed to study the oxidative stress-induced cytotoxicity and apoptotic cell death in human liver cells-HepG2 receiving experimental exposure of rotenone (12.5-250 μM) for 24 h. Rotenone depicted a dose-dependent cytotoxic response in HepG2 cells. These cytotoxic responses were in concurrence with the markers associated with oxidative stress such as an increase in ROS generation and lipid peroxidation as well as a decrease in the glutathione, catalase, and superoxide dismutase levels. The decrease in mitochondrial membrane potential also confirms the impaired mitochondrial activity. The events of cytotoxicity and oxidative stress were found to be associated with up-regulation in the expressions (mRNA and protein) of pro-apoptotic markers viz., p53, Bax, and caspase-3, and down-regulation of anti-apoptotic marker Bcl-2. The data obtain in this study indicate that rotenone-induced cytotoxicity in HepG2 cells via ROS-induced oxidative stress and mitochondria-mediated apoptosis involving p53, Bax/Bcl-2, and caspase-3.

Influence of iron metabolism indices on HbA1c in non-diabetic pregnant women with and without iron-deficiency anemia: effect of iron supplementation

AIMS

Condition that influence erythrocyte turnover also affect HbA1c. Although many forms of anemia are associated with lowering of HbA1c, iron-deficiency anemia (IDA) tends to increase HbA1c. In this study, we examined the relationship between HbA1c and erythrocyte indices in non-diabetic pregnancy and assessed the effect of iron supplementation on HbA1c.

MATERIALS AND METHODS

150 women were studied (30 non-diabetic), non-pregnant, non-anemic women in child bearing women with varying parity as controls (Gp 1); 30 non-diabetic, non-anemic pregnant women in first trimester of pregnancy (Gp 2a); 30 non-diabetic, non-anemic pregnant women in second trimester of pregnancy (Gp 2b); 30 non-diabetic, non-anemic pregnant women in third trimester of pregnancy (Gp 2c) and 30 non-diabetic pregnant women with IDA (Gp 2d). HbA1c, OGTT, erythrocyte indices and iron metabolic indices were determined in Gp 2d subjects not supplemented with iron and repeated these indices after 3 months of iron-supplementation.

RESULTS

The mean fasting and postprandial blood glucose levels (79.9±8.0mg/dl, 108.1±14.1mg/dl) in Gp 1 were found to be significantly lower in first trimester among Gp 2a (74.4±5.3mg/dl and 97.2±11.1mg/dl), in second trimester among Gp 2b (76.2±5.2mg/dl and 103.4±7.9mg/dl) followed by increase in IIIrd trimester among Gp 2c (82.3±5.7mg/dl and 112.5±8.5mg/dl) subjects. A significant difference in HbA1c was also observed among the groups (HbA1c 4.7±0.3% in Gp 1; 4.6±0.4% in Gp 2a; 4.5±0.3 in Gp 2b; 4.7±0.3 in Gp 2c). Among Gp 2d subjects, HbA1c was 5.2±0.3% and the level decreased after iron supplementation to 5.1±0.3%. Significant correlation between erythrocyte indices, iron metabolic indices and HbA1c was also observed.

CONCLUSION

We conclude that consideration should be given for performing glucose testing in patients with IDA to ascertain the reliability of HbA1c in the diagnosis of diabetes. HbA1c concentrations in diabetic patients with IDA should be interpreted with caution.

First Report of Citrus tristeza virus in National Germplasm of Citrus in Afghanistan

Rejuvenation of the horticulture industry is a government priority in Afghanistan. With that purpose, European Commission-supported programs specifically focus on greater access to improved and appropriate planting materials to increase the quantity and quality of more competitive horticultural products. Establishment of a biotechnology laboratory was considered essential support to horticulture sector development. This laboratory has begun screening the health status of the Afghan Germplasm National Collection to ensure multiplication of not only the best selected varieties or ecotypes but also to avoid reproduction and distribution of virus-infected fruit trees. Symptom inspection and sample collection for viral diseases was carried out in the citrus orchard during survey activity at the National Collection Experimental Farm in Jalalabad (Nangarhar Province). Ninety-nine variety plots (one row of five plants) were inspected visually and samples from two plants for each plot were collected and analyzed by double-antibody sandwich (DAS)-ELISA. Plants showing vein flecking, yellowing, and plant decline symptoms were observed in several plots. Four accessions were found to be infected by Citrus tristeza virus (CTV): kumquat cv. Margarita (isolates J4 and J8), orange cv. Mahali (J61), mandarin group cv. Fruter (J76), and rough lemon cv. Mahali (J101). Identified isolates have been characterized molecularly. A 655-nt fragment, corresponding to the major coat protein gene, has been amplified from all ELISA-positive samples by reverse transcription (RT)-PCR using CTVF (5'-TAATGGACGACGAACAAAGA-3') and CTVR (5'-CCAAGCTGCCTGACATTAGT-3') primers. Sequence analysis revealed high similarity, ranging from 91.1 to 99.8%, within CTV isolates detected in Jalalabad. In accordance with the phylogenetic groups previously defined (page 8 in: Proceedings of the 15th Conference of the International Organization of Citrus Virologists, 2002), nucleotide sequences of Afghan CTV isolates investigated in the current work cluster in Group 1 (J4 and J8), Group 4 (J61 and J76), and Group 5 (J101). In particular, J4 and J8 isolates show, respectively, identity of 99.4 and 99.2% with reference isolate T36 (GenBank Accession No. M76485) from the United States (Florida). Moreover, in Group 4, isolate J61 and J76 were more similar to ANO-1 isolate (GenBank Accession No. DQ211658) from Egypt (identity of 98.5 and 98.0%, respectively) than to isolate 443-4 (GenBank Accession No. AY791844) from Croatia (97.4 and 97.5%, respectively). Finally, isolate J101 in Group 5, shows identity of 95.6% with isolates C268-2 (GenBank Accession No. AY750770) and C269-6 (GenBank Accession No. AY750775) from Argentina. To our knowledge, our results identified for the first time CTV-infected plants in Afghanistan. The presence of CTV in four accessions of the national citrus collection is of concern for Afghan horticulture. Implementation of the certification schemes is therefore necessary to guarantee the production and the employment of virus-free propagating material.

Effect of Trans-resveratrol on Rotenone-induced Cytotoxicity in Human Breast Adenocarcinoma Cells

Rotenone, a botanical insecticide is known to cause apoptosis in various cell types. Trans-resveratrol, a natural phytophenol present in red grapes and wine, is also well documented for its antioxidant, anti-inflammatory, anti-mutagenic, and anticarcinogenic activities. Therefore, the present investigations were carried out to assess the protective effect of trans-resveratrol against rotenone-induced cell death in human breast adenocarcinoma (MCF-7) cells. MCF-7 cells were exposed with various concentrations of rotenone for 24 h, and the loss in percent cell viability was evaluated by MTT [3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide] and neutral red uptake (NRU) assays. A significant decrease in percent cell viability in MCF-7 cells was observed at 50 μM and above concentrations of rotenone, as compared to untreated control. Furthermore, various concentrations (5, 10, and 25 μM) of trans-resveratrol were used to see its protective role on cell viability in rotenone-induced cell death in MCF-7 cells. Pre- or post- treatment of trans-resveratrol for 24 h was given to the cells. The data exhibited a significant dose dependent increase in the percent cell viability under pre- and post-treatment conditions. However, post-treatment of trans-resveratrol for 24 h after rotenone exposure to the cells was relatively less effective. Overall, the results suggest that trans-resveratrol significantly protects MCF-7 cells from rotenone-induced cell death. This model can be used as an effective and economical alternative to animal models for screening the antioxidant activity of a variety of natural compounds/drugs.

Breast conservative surgery for operable invasive ductal carcinoma after neoadjuvant chemotherapy or hormonal therapy- a challenge for breast surgeon: a review based on literature and experience

Neoadjuvant chemotherapy or hormonal therapy is based on biological data and enables more patients to be treated with breast conserving surgery for locally advanced T2 and T3 without significantly increasing the rates of ipsilateral breast recurrence. Careful consideration of an optimal preoperative planning aims at accurately determining the patterns of primary tumour down staging and at the amount and location of any residual tumour in the breast, besides converting patients from mutilating surgery candidates to candidates for breast conservative procedure. The use of induction chemotherapy has the potential to improve the cosmetic results but free margins must be achieved and surgery must be planned in onco-plastic surgery. Axillary lymph node clearance is still the gold standard surgery in the treatment of the axilla. Sentinel lymph node biopsy can be done for clinically N0 patients but only in control trials.

KEYWORDS

Neoadjuvant systemic therapy, breast cancer surgery.

Epidemiology of Van der Woude syndrome from mutational analyses in affected patients from Pakistan

Mutations in IRF6 cause Van der Woude syndrome (VWS), one of the most common syndromes associated with cleft lip (CL) with or without cleft palate (CP). The presence of pits on the lower lip of patients is the most characteristic feature of the syndrome. We have identified three novel and seven previously reported IRF6 mutations in 12 of 16 unrelated families segregating VWS from Pakistan. The three newly identified mutations include a frameshift (c.568delG) and two missense mutations c.295G>A (p.G99S) and c.1219T>C (p.S407P). Recent functional studies on IRF6 and the three-dimensional structure of IRF5 carboxy (C) terminus, a protein encoded by a paralog of IRF6, shed light on the p.S407P substitution. Additionally, the identification of the same mutations responsible for VWS in Pakistan, as reported in other global populations worldwide, marks these residues as mutational hotspots and indicates their essential role in structural stability or function of IRF6. This is the first study of VWS in Pakistan and we estimate that 1 in 100 patients with CL with or without CP (CL/P) are affected in the Pakistani population predominantly from the Punjab area.

Serum cortisol and testosterone levels in idiopathic central serous chorioretinopathy

Context:

The preferential occurrence of idiopathic central serous chorioretinopathy (ICSC) in males with a typical Type A personality and behavior and a relative absence in females is a possible indicator towards the role of serum cortisol and /or the male sex hormone testosterone.

Aims:

To study levels of cortisol and testosterone in ICSC.

Settings and Design:

Case-control study in a tertiary care teaching hospital.

Materials and Methods:

The study was conducted on 23 cases of ICSC. Twelve patients with unilateral sudden painless loss of vision of less than one month duration served as controls. Serum cortisol and testosterone levels at 8.00 a.m. were estimated by radioimmunoassay in both groups.

Statistical analysis used:

Statistical analysis was done using SPSS 13.0 software. Independent Sample t-test was applied to analyze statistical significance between the two groups.

Results:

Mean age of patients with ICSC was 37.1 ± 9.7 years and 96% of the patients were males. Mean serum cortisol levels were significantly higher (P=0.002) in patients with ICSC i.e., 495.02 ± 169.47 nano moles/liter (nmol/L) as compared to controls i.e., 362.25 ± 51.54 nmol/L. Mean serum testosterone levels were 3.85 ± 1.81 nano grams/ml (ngm/ml) and 4.23 ± 1.89 ngm/ml in cases and controls respectively and the difference was not statistically significant (P=0.58).

Conclusions:

ICSC is associated with elevated 8.00 a.m. serum cortisol levels. However, mean serum testosterone levels in both patients of ICSC and controls were within normal range.

Laparoscopic cardiomyotomy for achalasia: A single unit study

AIMS

Achalasia is a rare incurable neuromuscular disorder of the oesophagus. A number of treatment options are available. We reviewed our results of laparoscopic cardiomyotomy over a 30 month period.

METHODS

18 patients with manometric features of achalasia underwent surgery between 2004 and 2006. Pre and postoperative weight and dysphagia scores were recorded (maximum score 45=normal, 0=complete dysphagia). Change in the Body Mass Index (BMI) was measured. Other symptoms (heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance) were scored on a 0-4 scale of increasing severity.

RESULTS

At mean follow up of 16.2 months the mean dysphagia score was significantly improved from 7.5 to 33.9 (p<0.005). BMI was significantly increased from 22.3 to 25.8 kg/m(2) (p<0.05). Scores for heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance were also significantly improved. The average inpatient stay was 3.1 days and average operating time 111 minutes. One mucosal perforation occurred which was repaired intraoperatively. No patients required secondary operative intervention.

CONCLUSIONS

Laparoscopic cardiomyotomy is a safe, highly effective, minimally invasive treatment for achalasia.

Outcome after liver transplantation for NASH cirrhosis

Nonalcoholic steatohepatitis (NASH) associated cirrhosis is an increasing indication for liver transplant (LT). The aim of this study was to determine outcome and poor predictive factors after LT for NASH cirrhosis. We analyzed patients undergoing LT from 1997 to 2008 at a single center. NASH was diagnosed on histopathology. LT recipients with hepatitis C, alcoholic or cholestatic liver disease and cryptogenic cirrhosis acted as matched controls. Ninety-eight LT recipients were identified with NASH cirrhosis. Compared to controls, NASH patients had a higher BMI (mean 32.3 kg/m2), and were more likely to be diabetic and hypertensive. Mortality after transplant was similar between NASH patients and controls but there was a tendency for higher earlier mortality in NASH patients (30-day mortality 6.1%, 1-year mortality 21.4%). Sepsis accounted for half of all deaths in NASH patients, significantly higher than controls. NASH patients > or =60 years, BMI > or =30 kg/m2 with diabetes and hypertension (HTN) had a 50% 1-year mortality. In conclusion, patients undergoing LT for NASH cirrhosis have a similar outcome to patients undergoing LT for other indications. The combination of older age, higher BMI, diabetes and HTN are associated with poor outcome after LT. Careful consideration is warranted before offering LT to these high-risk patients.

Portal hypertension and hypersplenism in a patient with a Bochdalek hernia: a case report

BACKGROUND

A congenital diaphragmatic hernia (Bochdalek's hernia) rarely presents in adulthood.

CASE PRESENTATION

We present the case of a 21-year-old woman with thrombocytopenia secondary to hypersplenism due to left-sided (sinistral) portal hypertension. This portal hypertension was caused by strangulation of the spleen within a Bochdalek's hernia. Subacute gastric volvulus compounded by portal hypertensive gastropathy resulted in her presentation with acute haematemesis.

CONCLUSIONS

Congenital diaphragmatic hernias may present in the adult. Their presentation is variable, and they may produce life-threatening complications.

Inflammatory markers, insulin resistance and carotid intima-media thickness in North-Indian type 2 diabetic subjects

OBJECTIVE

To study the interrelationship of the inflammation, insulin resistance and atherosclerosis in recently diagnosed type 2 diabetes.

METHODOLOGY

Eighty-one newly diagnosed type 2 diabetic patients were compared with 81 healthy age, sex and BMI matched controls. Plasma glucose and insulin (fasting and after 2 hours of 75 gm of oral glucose), lipids and serum levels of C-reactive protein (CRP), fibrinogen and Tumour Necrosis Factor (TNF)-alpha were measured. Carotid (Intima-Medial Thickness) IMT was measured using high "resolution B-Mode ultrasonography. Insulin resistance was calculated using HOMA-IR model. Electrocardiogram (ECG) and exercise ECG were recorded for the evidence of coronary heart disease (CHD).

RESULTS

Carotid IMT was significantly thicker in diabetic patients than in control group across the whole age range (p < 0.01). In merged group of diabetes, composite IMT was significantly correlated with LDL-cholesterol, fasting insulin, serum cholesterol, BMI and HOMA-IR (p < 0.01). After controlling for age and sex, all glycaemic parameters were correlated with IMT in both diabetic and control group. HOMA-IR, waist hip ratio, serum triglycerides, serum cholesterol, fasting serum insulin and CRP were significant predictor of IMT. Concentrations of inflammatory markers were significantly higher in diabetic patients than in control group. Serum levels of CRP (p < 0.05) were found to be higher in diabetic patients with CHD than without CHD. CRP was significantly correlated with IMT (r = 0.603, p < 0.01) in diabetic subjects with and without CHD after controlling for age and sex.

CONCLUSION

Inflammatory markers are associated with type 2 diabetes but only CRP is associated with development of accelerated atherosclerosis and subsequent CHD.

Wernicke's encephalopathy after laparoscopic cardiomyotomy for achalasia

Achalasia is an incurable neuromuscular disorder of the esophagus, resulting from destruction of the esophageal myenteric plexus. This leads to aperistalsis and failure of the lower esophageal sphincter to relax after swallowing. Symptoms of achalasia are gradual in onset and include dysphagia, regurgitation, and weight loss. Severe malnutrition can ensue. Wernicke's encephalopathy (WE) is a serious, potentially fatal, neurologic disorder caused by thiamine deficiency (vitamin B(1)), classically described as presenting with a triad of ocular abnormalities, ataxia, and confusion. The incidence is uncertain, and many cases likely go unrecognized. It is usually diagnosed in the alcoholic population. We describe its onset after the successful surgical treatment of achalasia.

Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial

INTRODUCTION

Topical glyceryl trinitrate (GTN) has gained popularity as a treatment for anal fissure in the West. In our country, lignocaine is still the current treatment for the entity. This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population.

METHODS

A prospective, double blinded, randomised controlled trial was conducted on 50 patients (both treatment arms included) of all ages and either gender with a clinical diagnosis of anal fissure. Group A was given 0.2% GTN ointment and Group B was given lignocaine ointment. Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought.

RESULTS

Symptomatic relief was earlier with GTN as compared with lignocaine. Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 80% of patients in Group A showed clinical signs of healing compared to 32% in Group B (p=0.001). Headache was the main side effect of GTN. At 6-month follow-up, recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group (p=1).

CONCLUSION

Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects. The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population.