Metabolic dysfunction-associated fatty liver disease and low muscle strength: A comment

The diagnosis of non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease only on the basis of laboratory parameter score such as Hepatic Steatosis Index which includes liver enzymes, gender, basal metabolic index, and presence of diabetic mellitus is not sufficient to exclude other causes of deranged liver enzymes especially medications and autoimmune related liver diseases. As the guideline suggests ultrasound is the preferred first-line diagnostic procedure for imaging of NAFLD, as it provides additional diagnostic information and the combination of biomarkers/scores and transient elastography might confer additional diagnostic accuracy and evident from previous similar studies too.

Recurrence of portosystemic encephalopathy in cirrhotic patients and its risk factors

Objectives

Recurrent episodes of Portal Systemic Encephalopathy (PSE), poses a significant burden of illness on the patients and healthcare system. The objective of this study was to assess the recurrence of PSE in cirrhotic patients after index episode of PSE and to identify various risk factors associated with it.

Methods

A retrospective, single-centre study was conducted at Aga Khan University Hospital over a span of one year. Patients who were admitted first time with PSE and admitted within three months of index PSE were enrolled in the study. Variables assessed were demographic data, associated comorbid conditions, aetiology of cirrhosis, Child-Turcotte-Pugh (CTP) score, Model of End-Stage Liver Disease (MELD) score, PSE grade, laboratory tests, ascites with spontaneous bacterial peritonitis (SBP), variceal bleeding. Statistical analysis was done and variables of those who developed recurrence were compared with those who did not.

Results

Fifty one patients were recruited. Thirty three (64.7%) were readmitted with PSE. On comparative analysis of both groups; infection, Meld score, low albumin, and raised total bilirubin showed significant P-value (<0.05).

Conclusion

Identification of risk factors during assessment can reduce the recurrence of PSE. We would recommend to validate result of our study on a large scale prospectively.

A Clinical Study on Gallbladder Polyp

There are different types of gallbladder polyps having variable morphology and nature. Symptoms are vague and mostly diagnosed incidentally on abdominal ultrasound. Risk factors are many. Indications of surgery are not clearly understood due to lack of clinical evidence. This study was carried out to analyze the management of gallbladder polyp in our settings and review of available evidence. Patients who underwent clip less mini laparoscopic cholecystectomy for gallbladder polyp were included. Clinical data including short history, age, gender, parity, lab tests, ultrasound report and macroscopy were recorded during surgery. Histopathology reports collected later. Total of 112 patients with mean age 42.6 years (range 22-82), 74 of whom were female. Most of them (46.42%) were asymptomatic. Single polyp was in 69, multiple in 32 and polyp with stone in 8 patients. Sessile polyp was 74.10%. Average polyp size was 7.6mm. Cholesterol polyp was in 82 patients. Four out of 5 malignant polyps were single and sessile. Abdominal ultrasound is the mainstay of diagnosis of gallbladder polyp but size, location, morphology, number and presence of associated gallstone has to be mentioned. Symptomatic gallbladder polyp benefited from surgery. Polyps more than 6mm, single and sessile morphology above the age 50 should undergo cholecystectomy.

Intermittent prophylaxis of recurrent febrile seizures with clobazam versus diazepam

Febrile seizures are the most common type of seizure among children that can be prevented by using prophylactic drugs like Clobazam and Diazepam. The present prospective study was conducted in the Department of Pediatrics, Mymensingh Medical College Hospital and Community Based Medical College Hospital, Bangladesh over a period of 1 year from July 2012 to June 2013 to compare the effectiveness of intermittent Clobazam versus Diazepam therapy in preventing the recurrence of febrile seizures and assessed adverse effects of each drug. A total of 65 patients (32 children administered Clobazam and rest 33 children received Diazepam) of simple and complex febrile seizures aged 6 months to 5 years of both sexes were the study population. Data were collected by interview of the patients, clinical examination and laboratory investigations using the research instrument. Data were analyzed by using Chi-square (χ2) Test, Student's 't' Test and Fisher's Exact Test. For all analytical tests, the level of significance was set at 0.05 and p<0.05 was considered significant. The proportion of patients was higher between age 12-36 months and male was predominant in the both Clobazam and Diazepam groups. Over 31% of patients in Clobazam group who experienced episode of fever within 3 months, 40.6% within 6 months and 9.4% within 9 months compared to 36.4% in Diazepam group within 3 months, 45.5% within 6 months & 12.1% within 9 months after discharge from the hospital. Three (9.4%) patients in Clobazam group and 7(21.3%) in Diazepam group who experienced febrile convulsion during the follow up period. From the data adverse effects within 3 and 6 months experienced by the patient's drowsiness, sedation and ataxia were higher in Diazepam group than those in Clobazam group. However, within 9 months lethargy and irritability were somewhat higher in Clobazam group than those in Diazepam group. The mean duration of hospitalization was significantly higher in Diazepam group compared to Clobazam group (6.0±1.0 vs. 4.6±0.08 days, P<0.001). Seven (21.2%) out of 33 children with febrile seizures in Diazepam group had a history of recurrent seizures, whereas 3(9.4%) of 32 children in the Clobazam group. The risks of recurrent febrile seizure in the Diazepam group was 2.6 times greater compared to those in the Clobazam group (P=0.186). The result indicates that Clobazam is safe, efficacious, requires less frequent dosing and has less adverse effects such as drowsiness, sedation, ataxia and irritability as compared to Diazepam. So, Clobazam may be an alternative to Diazepam given intermittently for prevention of recurrent febrile seizures.

Intravascular catheter related infections and antimicrobial susceptibility pattern of isolated bacteria in a tertiary care hospital of Bangladesh

The aim of this study was to evaluate the rate of bacterial colonisation and catheter related blood stream infections (CRBSI) together with the antibiotic susceptibility patterns in a tertiary care hospital. CRBSI was detected with semi-quantitative and quantitative methods. The antimicrobial susceptible patterns of the isolated organisms were performed by Kirby Bauer disk diffusion method. The rate of catheter colonisation and CRBSI were 42.1% and 14% (16.1/1000 catheter days) respectively. The most common causative pathogens were Pseudomonas sp. (23.7%), Acinetobacter sp. (18.4%), Staphylococcus aureus (13.2%) and Enterobacteriaceae (10.5%). The rate of isolation of methicillin resistance S. aureus, imipenem resistant Pseudomonas sp. and extended spectrum β lactamase producing Enterobacteriaceae were 60%, 44.0% and 100%. The result of this study would be useful for control and treatment of CRBSI.

Ventral free oral mucous membrane graft for bulbar urethral stricture

The use of oral mucous membrane graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. We investigated the short term result of oral mucous membrane graft placed on the ventral surface for management of bulbar urethral stricture. Patients with Bulbar urethral stricture of any length, infection free urinary tract and informed consent for oral mucosa harvesting and urethroplasty were selected for study. We enrolled 108 cases of bulbar urethral stricture patients from January 2004 to July 2009. The mean ± SD preoperative maximum flow rate of 5.2 ± 2.6 ml/sec and mean ± SD PVR 87 ± 58.3 ml were treated by substitution urethroplasty with oral mucous membrane by a single surgical team in a private hospital. Causes of stricture were trauma 26(24.1%), infection 58(53.7%), catheter induced 8(7.4%), post TURP 11(10.2%) and unknown 5(4.6%). Oral mucous membrane was harvested from the cheek or from the inner side of lower lip. Defect of the urethra displayed by longitudinal ventral urethrotomy and the graft was sutured over the edges of the incised urethral mucosa over a 14 Fr latex Foley's catheter. Spongiosum tissue was closed over the graft. Pericatheter urethrogram was performed in all cases to check for the anastomotic leakage and the Catheter was removed after 2 weeks of the procedure. After removal of catheter uroflowmetry & ultrasound scan of bladder were performed to estimate the maximum flow rate and post voidal residue. The patient was followed-up every 3 months with uroflowmetry & ultrasonography. The median (range) age of the patients was 32(21-72) years. Mean follow up period was 36 months (range 12-54). Mean ± SD stricture length was 3.7 ± 2.6 cm. The overall success rate was 91.7%. Mean ± SD flow rate was 23 ± 4.2 ml/sec, mean ± SD post void residue was 25 ± 15.5 ml and patient quality of life (QOL) was excellent in almost all patients. Overall complications were seen in 9(8.3%) cases. Of which, restricture occurred in 6 patients; periurethral fistulae seen in 2 cases and per urethral bleeding in 1 patient. No significant complications were observed at the donor site. Oral numbness and mild discomfort complained by 67.6% patients which were managed by reassurance only. In our experience ventral placement of oral mucous membrane graft along with spongioplasty is a very easy procedure with very encouraging short term result.

Efficacy and tolerability of racecadotril in the treatment of cholera in adults: a double blind, randomised, controlled clinical trial

BACKGROUND

The enkephalins, endogenous opiate substances, act as neurotransmitters along the entire digestive tract where they elicit intestinal antisecretory activity without affecting intestinal transit time or motility. Racecadotril, through inhibition of enkephalinase, reinforces the physiological activity of endogenous enkephalins and, therefore, shows intestinal antisecretory activity.

AIM

We conducted the study to determine the role of racecadotril as an adjunct to the standard treatment of cholera in adults.

METHODS

The study was a double blind, randomised, placebo controlled clinical trial involving 110 adult male cholera patients who received either racecadotril or placebo in addition to standard cholera treatment. The major outcome measures (stool output, oral rehydration solution (ORS) intake, requirements for unscheduled intravenous fluid infusion, and duration of diarrhoea) were compared between the groups.

RESULTS

Of 110 patients enrolled, 54 received racecadotril and 56 received placebo. Admission clinical characteristics were comparable between the groups. There was no significant difference in (mean (SD)) total stool output (racecadotril v placebo 315 (228) v 280 (156) g/kg), total ORS intake (390 (264) v 369 (240) ml/kg), or duration of diarrhoea (35 (15) v 32 (13) hours) between the groups. Clinical success, defined as resolution of diarrhoea within 72 hours of initiation of study intervention, was similar in both groups (racecadotril v placebo 96% v 89%). The number of patients receiving unscheduled intravenous infusions was not significantly different between the groups (racecadotril v placebo 22% v 14%). No drug related adverse effect was noted.

CONCLUSION

The study demonstrated that racecadotril therapy, although found to be safe, does not provide additional benefit in the treatment of severe cholera in adults.

A quantitative molecular model for modulation of mammalian translation by the eIF4E-binding protein 1

Translation initiation is a key point of regulation in eukaryotic gene expression. 4E-binding proteins (4E-BPs) inhibit initiation by blocking the association of eIF4E with eIF4G, two integral components of the mRNA cap-binding complex. Phosphorylation of 4E-BP1 reduces its ability to bind to eIF4E and thereby to compete with eIF4G. A novel combination of biophysical and biochemical tools was used to measure the impact of phosphorylation and acidic side chain substitution at each potentially modulatory site in 4E-BP1. For each individual site, we have analyzed the effects of modification on eIF4E binding using affinity chromatography and surface plasmon resonance analysis, and on the regulatory function of the 4E-BP1 protein using a yeast in vivo model system and a mammalian in vitro translation assay. We find that modifications at the two sites immediately flanking the eIF4E-binding domain, Thr(46) and Ser(65), consistently have the most significant effects, and that phosphorylation of Ser(65) causes the greatest reduction in binding affinity. These results establish a quantitative framework that should contribute to understanding of the molecular interactions underlying 4E-BP1-mediated translational regulation.

Cox-2 expression in retinoblastoma

PURPOSE

Cox-2, a prostaglandin synthase, is overexpressed in colorectal cancers and is involved in angiogenesis as well as in tumorigenesis. In this study, we investigate the expression of Cox-2 in retinoblastoma.

METHODS

Twenty-nine formalin-fixed retinoblastoma specimens were examined by the labeled-streptavidin-biotin method using anti-Cox-2 antibody.

RESULTS

Cox-2 positive immunoreactions were observed in 28 (96%) of 29 retinoblastomas specimens.

CONCLUSION

This preliminary study suggests the overexpression of Cox-2 in both differentiated and undifferentiated retinoblastoma and its possible role in tumorigenesis.

Orbital cholesterol granuloma with destruction of the lateral orbital roof

PURPOSE

Orbital cholesterol granuloma in a 51-year-old man is described.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) were done.

RESULTS

Both studies showed a mass in the left orbit, with evidence of orbital roof destruction in the CT scan. On the basis of clinical and imaging findings, a diagnosis was made of malignant orbital tumor with destruction of the lateral orbital roof. Surgical exploration revealed a thickly encapsulated mass densely adherent to the left superior orbital bone and periosteum. Although the dura mater was intact, bone destruction in the lateral orbital roof was seen. The entire mass was successfully excised and histopathological evaluation was performed. Histopathology showed numerous inflammatory cells, blood degradation products, and cholesterol clefts. The absence of epithelial elements led to the diagnosis of cholesterol granuloma.

CONCLUSIONS

Care must be taken to differentiate cholesterol granuloma from malignant orbital tumor. CT scan and MRI imaging seem well-suited to detecting the characteristic findings of cholesterol granuloma.

Lipopolysaccharide- and cholera toxin-specific subclass distribution of B-cell responses in cholera

The immunoglobulin subclass responses to homologous lipopolysaccharide (LPS) and to cholera toxin (CT) in adult patients infected with Vibrio cholerae O1 and V. cholerae O139 were studied. LPS-specific antibody-secreting cells (ASC) of both the immunoglobulin A1 (IgA1) and IgA2 subclasses were seen, with the IgA1 ASC response predominating in both V. cholerae O1- and O139-infected patients. For antibodies in plasma, by day 11 after onset of disease, all V. cholerae O1- infected patients responded to homologous LPS with the IgA1 subclass (P = 0.001), whereas fewer (68%) responded with the IgA2 subclass (P = 0.007). About 89% of V. cholerae O139-infected patients responded with the IgA1 subclass (P = 0.003), and only 21% responded with the IgA2 subclass (not significant [NS]). Both groups of cholera patients showed significant increases in LPS-specific IgG1, IgG2, and IgG3 antibodies in plasma. In feces, the response to homologous LPS occurred in both groups of patients with the IgA1 and IgA2 subclasses, with 55 to 67% of patients showing a positive response. V. cholerae O1- and O139-infected patients showed CT-specific ASC responses of the different IgG and IgA subclasses in the circulation, and the pattern followed the order IgG1 > IgA1 > IgG2 > IgA2, with low levels of IgG3 and IgG4 ASC. Plasma anti-CT antibody responses in all subclasses were seen by day 11 after onset of disease. Although there were no increases in CT-specific ASC of the IgG3 (NS) and IgG4 (NS) subtypes, there were significant increases of these two subclasses in plasma (P </= 0.001). The response to CT in the fecal extracts was contributed to by both IgA1 and IgA2 isotypes, with 67 to 75% of the patients responding. Thus, the mucosa-derived ASC and fecal antibodies to LPS and CT were of both the IgA1 and IgA2 subclasses; in plasma, the contribution from IgA2 was lower. Very little difference in the B-cell responses to LPS and CT in the different subclasses was seen in the two groups of cholera patients. Vaccines against O1 and O139 cholera ideally should stimulate antibody subclasses that are likely to offer protection.

Repressor binding to a dorsal regulatory site traps human eIF4E in a high cap-affinity state

Eukaryotic translation initiation involves recognition of the 5' end of cellular mRNA by the cap-binding complex known as eukaryotic initiation factor 4F (eIF4F). Initiation is a key point of regulation in gene expression in response to mechanisms mediated by signal transduction pathways. We have investigated the molecular interactions underlying inhibition of human eIF4E function by regulatable repressors called 4E-binding proteins (4E-BPs). Two essential components of eIF4F are the cap-binding protein eIF4E, and eIF4G, a multi-functional protein that binds both eIF4E and other essential eIFs. We show that the 4E-BPs 1 and 2 block the interaction between eIF4G and eIF4E by competing for binding to a dorsal site on eIF4E. Remarkably, binding of the 4E-BPs at this dorsal site enhances cap-binding via the ventral cap-binding slot, thus trapping eIF4E in inactive complexes with high affinity for capped mRNA. The binding contacts and affinities for the interactions between 4E-BP1/2 and eIF4E are distinct (estimated K(d) values of 10(-8) and 3x10(-9) for 4E-BP1 and 2, respectively), and the differences in these properties are determined by three amino acids within an otherwise conserved motif. These data provide a quantitative framework for a new molecular model of translational regulation.

Translational repression by human 4E-BP1 in yeast specifically requires human eIF4E as target

4E-binding proteins (4E-BPs) are believed to have important regulatory functions in controlling the rate of translation initiation in mammalian cells. They do so by binding to the mRNA cap-binding protein, eIF4E, thereby inhibiting formation of the cap-binding complex, a process essential for cap-dependent translation initiation. We have reproduced the translation-repressive function of human 4E-BP1 in yeast and find its activity to be dependent on substitution of human eIF4E for its yeast counterpart. Translation initiation and growth are inhibited when human 4E-BP1 is expressed in a strain with the human eIF4E substitution, but not in an unmodified strain. We have compared the relative affinities of human 4E-BP1 for human and yeast eIF4E, both in vitro using an m7GTP cap-binding assay and in vivo using a yeast two-hybrid assay, and find that the affinity of human 4E-BP1 for human eIF4E is markedly greater than for yeast eIF4E. Thus yeast eIF4E lacks structural features required for binding to human 4E-BP1. These results therefore demonstrate that the features of eIF4E required for binding to 4E-BP1 are distinct from those required for cap-complex assembly.

Demonstration of S-100 protein immunoreactivity in normal human retina and retinoblastoma

Specimens of 24 enucleated eyes from patients with retinoblastomas in situ were examined by labelled streptavidin biotin (LSAB) method to ascertain the distribution of S-100 protein and compared with 28 normal developing eyes. Polyclonal anti-S-100 antiserum and monoclonal alpha and beta chain anti-S-100 antibodies were used in this study. In the normal retina a weak reaction was observed in astrocytes and ganglion cells at 24 gestational weeks (GW) and there was an increase in the intensity of staining with increasing age. In the morphologically normal retina with retinoblastoma, astrocytes, ganglion cells and Müller cells showed positive reactions for S-100 protein. Examined tumors showed S-100 protein-positive glial cells that were interpreted as reactive astrocytes. No reaction product was detected in the tumor cells. These findings support the concept that in the retinoblastoma, only glial cells are positive for S-100 protein.

Eccrine adenocarcinoma of the lacrimal sac region

Eccrine adenocarcinoma of the lacrimal sac region is described in a 48-year-old man. The case was first diagnosed as an adenocarcinoma and removed by dacryocystectomy, but unfortunately the neoplasm recurred after a period of 1 year. Examinations with periodic acid-Schiff (PAS) and several antibodies indicate that this is a hitherto undescribed eccrine adenocarcinoma, and finally the case was managed by orbital exenteration. This is the first case of eccrine adenocarcinoma of the lacrimal sac region to be documented in the world literature.

Clinical and electron microscopic features of retinoblastoma

A male child of 1-year, 6-month-old had a history of leukocoria of the left eye for approximately three months prior to admission into our facility. No abnormality was found in the right eye. There was negative family history of retinoblastoma. Ophthalmoscopy revealed a white mass extending from the supero-posterior part of the left globe to the posterior surface of the lens. Orbital tomograms showed no intraocular tissue densities in the mass but a B-scan ultrasound showed an echo dense area of the mass. Histopathologically areas of photoreceptor differentiation and Flexner-Wintersteiner rosettes were observed in the tumor mass by light microscope. Transmission electron microscopy disclosed the presence of prominent mitochondria on the luminal side of the cells forming rosettes and these were believed to be the component parts of the inner-segments of the photoreceptor cells. The results of this study indicate a predominant neuronal nature of the neoplastic cells with photoreceptor-like differentiation.

Retinoblastoma: clinical and immunocytochemical observations

The clinical features of three cases of retinoblastoma and the histopathological and immunocytochemical findings of the retinoblastoma specimens of these patients are described. The other eye of each patient was normal. There was no family history of retinoblastoma. Fundal examination disclosed white masses in the posterior segments of the eyes. B-scan ultrasonography showed echo dense areas in the masses. Orbital tomograms showed no evidence of tissue densities. There was neither extraocular extension nor optic nerve involvement. Immunocytochemistry of paraffin-embedded tissues of the neoplasms revealed immunoreactivity with antibodies against S-100 protein, glial fibrillary acidic protein(GFAP), vimentin, neuron-specific enolase(NSE) and bcl-2. S-100, GFAP and vimentin were positive only for glial elements(reactive astrocytes) and, NSE and bcl-2 for almost all tumor cells. These findings support the previous reports that the majority of retinoblastomas are sporadic. The results of this study also support the views that retinoblastomas are composed of neuron-committed cells.

Glial fibrillary acidic protein expression in the developing human retina

We have studied the expression of glial fibrillary acidic protein(GFAP), an astrocyte specific protein in the normal developing human retina using anti-GFAP antibody. GFAP positive cells were first detected at 24 gestational weeks(GW) in the nerve fiber and ganglion cell layers in the vicinity of the optic disc. Over subsequent weeks, GFAP positive cells covered larger regions of the retina. Some of the processes of these cells terminated in sucker like end-feet upon blood vessels of the nerve fiber layer. A second population of GFAP positive cells existed as perivascular glia in the nerve fiber layer in the early stage of fetal development. In the adult retina perivascular glia were found on vessels throughout the nerve fiber and in the inner portion of the inner plexiform layers. Staining of Müller cells end-feet was obtained only in the adult retina. These results support the views that in the human retina, GFAP positive cells first appear at 24 GW in the region near the optic disc, covering the whole retina at subsequent ages.

Mixed cell malignant melanoma of the ciliary body

Malignant melanomas of the ciliary body are uncommon tumors and the ratio of occurrence in the ciliary body to that in the choroid is 1:10. These tumors may have a nodular or diffuse growth pattern or combination of the two. The authors recently encountered a malignant melanoma of the ciliary body. After evaluation of the results of clinical examination, computed tomography(CT) and magnetic resonance imaging(MRI) a tentative diagnosis of malignant melanoma of the ciliary body in the left eye was made and an enucleation was done. Histopathological examination revealed the case as a mixed cell malignant melanoma of the ciliary body. The patient was followed up for approximately one year with no signs of metastasis or recurrence.

Epitheloid cell malignant melanoma of the conjunctiva

Primary malignant melanoma of the conjunctiva is an uncommon neoplasm comprising only 2% of the malignant tumors of the eye. The tumors are usually composed of epitheloid, spindle or mixed cells and classified according to the predominant cells. Recently we encountered a conjunctival malignant melanoma occurring in a man. After full clinical and laboratory investigations, a clinical diagnosis of malignant melanoma of the conjunctiva in the left eye was entertained. The tumor was resected under local anesthesia and upon histological examination, the case was confirmed as a conjunctival malignant melanoma. Approximately one month after resection, orbital exenteration was carried out. The patient was followed-up for more than a year with no signs of metastasis or recurrence.

Inflammatory pseudotumor of the lacrimal sac

A case of inflammatory pseudotumor of the lacrimal sac is presented. The patient was first consulted for epiphora and swelling of the right lacrimal sac region. A mass was found on computed tomography (CT) and finally it was removed by dacryocystectomy. The diagnosis of inflammatory pseudotumor was confirmed by histopathological sections.