Results of in situ fixation of Andersson lesion by posterior approach in 35 cases

STUDY OBJECTIVE

Due to the rarity of the Andersson lesion (AL), the literature is ambiguous regarding the type of surgical fixation, need for debridement and deformity correction. The purpose of this retrospective study is to evaluate the efficacy, feasibility and functional outcome of posterior fixation in AL.

MATERIALS AND METHODS

This study included 35 patients having thoracolumbar AL operated for in situ fixation and fusion with minimum of 24-month follow-up. VAS (Visual Analogue Score) back pain, ODI (Oswestry Disability Index), Frankel's grade were compared and analyzed. Union status was noted with complications.

RESULTS

The mean age of 35 patients was 56.34(± 11.3) years with average follow-up of 51.49 months. Two patients had AL at two levels. 27/37 AL were at discal level. Average estimated blood loss (EBL) was 276.43 ml and duration of surgery was 130.43 min. On an average, operated segments needed 7.77 screws. There were ten minor complications without long-term sequel. Neurological improvement was noted in 30 patients. Average preoperative VAS score improved from 8.69 to 3.14, ODI score improved from 68.76 to 18.77 at final follow-up which were significant (p < 0.05). There was significant improvement in Frankel's grading (Z = - 4.354, P = 0.00).

CONCLUSIONS

Surgical management of AL by posterior approach and posterior stabilization can give satisfactory results without the need of extensive anterior reconstruction, bone grafting or deformity correction procedures without added morbidity and complications.

Thoracic Spine Stenosis: Does Ultrasonic Osteotome Improve Outcome in Comparison to Conventional Technique?

INTRODUCTION

To investigate the efficacy of Ultrasonic Bone Scalpel (UBS) in thoracic spinal stenosis (TSS) in comparison to traditional technique.

MATERIAL AND METHODS

A total of 55 patients who had undergone conventional surgery (Group A) are compared with 45 patients of UBS (Group B) in TSS. The primary outcome measure of Modified Japanese Orthopaedic Association score (m JOA) with neurological complications and dural injury were assessed. Secondary outcome measures of total blood loss (TBL), time duration of surgery (ORT) and length of hospital stay (LHS) were analysed.

RESULTS

The pre-operative mJOA score 5.00(4.00-6.00) in the group A and 5.00(4.00-6.00) in the group B improved to 7.00(7.00-8.00) in the group A and 9.00(9.00-10.00) in the group B, respectively (P<0.001) at final average follow-up of 117.55 months for group A and 75.69 months in group B. More significant grade of myelopathy improvement and mJOA recovery rate (RR) were noted in group B. The TBL, ORT and LHS were more favourable in group B as compared to group A (p<0.0001). The group A had 9 (16.36%) neurological deficits compared to 2 (4.44%) in group B (p<0.001). Dural tears occurred in both groups (A=11, B=9). It was more frequent and not repairable in group A but without significant statistical difference.

CONCLUSION

UBS can reduce neurological deficits and improve outcomes in TSS. Secondarily, reduced blood loss, lesser surgical time and reduced LHS are significant added advantages of this new technology.

Management of Corneal Bee Sting Injuries

PURPOSE

To review the management of keratitis after corneal bee stings and to report a case of deep stromal corneal infiltrate secondary to a retained bee stinger managed conservatively in a patient who presented three days after unsanitary manipulation of the stinger apparatus.

METHODS

Case report and review of literature.

RESULTS

A 57-year-old male beekeeper was evaluated for pain, blurry vision, and photosensitivity after a corneal bee sting. Of note, the venom sac had been removed with dirty tweezers three days prior to his visit. On exam, a focal infiltrate with diffuse edema was seen surrounding a retained bee stinger in the peripheral cornea. Trace cells in the anterior chamber were also noted. Based on a high suspicion for infectious keratitis, a conservative treatment strategy was elected. Administration of broad-spectrum topical antibiotics with concomitant abstention of corticosteroids led to rapid resolution of the symptoms. Over 16 months of follow-up, the stinger has remained in situ without migration and the patient has maintained 20/20 visual acuity without complications. There is debate on the preferred method for the management of corneal injury secondary to bee stings, especially when it is associated with a retained stinger. We herein present our findings in our appraisal of reported cases.

CONCLUSION

In the aftermath of an ocular bee sting, close surveillance for inflammation and infection is essential. Individual manifestations of these injuries vary in timing, type, and severity; therefore, the accessibility of the stinger and the evolving clinical picture should guide therapeutic decisions.

Subretinal AAV2.COMP-Ang1 suppresses choroidal neovascularization and vascular endothelial growth factor in a murine model of age-related macular degeneration

To assess whether Tie2-mediated vascular stabilization ameliorates neovascular age-related macular degeneration (AMD), we investigated the impact of adeno-associated virus-mediated gene therapy with cartilage oligomeric matrix protein angiopoietin-1 (AAV2.COMP-Ang1) on choroidal neovascularization (CNV), vascular endothelial growth factor (VEGF), and hypoxia-inducible factor (HIF) in a mouse model of the disease. We treated mice with subretinal injections of AAV2.COMP-Ang1 or control (AAV2.AcGFP, AAV2.LacZ, and phosphate-buffered saline). Subretinal AAV2 localization and plasmid protein expression was verified in the retinal pigment epithelium (RPE)/choroid of mice treated with all AAV2 constructs. Laser-assisted simulation of neovascular AMD was performed and followed by quantification of HIF, VEGF, and CNV in each experimental group. We found that AAV2.COMP-Ang1 was associated with a significant reduction in VEGF levels (29-33%, p < 0.01) and CNV volume (60-70%, p < 0.01), without a concomitant decrease in HIF1-α, compared to all controls. We concluded that a) AAV2 is a viable vector for delivering COMP-Ang1 to subretinal tissues, b) subretinal COMP-Ang1 holds promise as a prospective treatment for neovascular AMD, and c) although VEGF suppression in the RPE/choroid may be one mechanism by which AAV2.COMP-Ang1 reduces CNV, this therapeutic effect may be hypoxia-independent. Taken together, these findings suggest that AAV2.COMP-Ang1 has potential to serve as an alternative or complementary option to anti-VEGF agents for the long-term amelioration of neovascular AMD.

Intravitreal AAV2.COMP-Ang1 Prevents Neurovascular Degeneration in a Murine Model of Diabetic Retinopathy

Diabetic retinopathy (DR) is the leading cause of blindness in the working-age population in the U.S. The vision-threatening processes of neuroglial and vascular dysfunction in DR occur in concert, driven by hyperglycemia and propelled by a pathway of inflammation, ischemia, vasodegeneration, and breakdown of the blood retinal barrier. Currently, no therapies exist for normalizing the vasculature in DR. Here, we show that a single intravitreal dose of adeno-associated virus serotype 2 encoding a more stable, soluble, and potent form of angiopoietin 1 (AAV2.COMP-Ang1) can ameliorate the structural and functional hallmarks of DR in Ins2Akita mice, with sustained effects observed through six months. In early DR, AAV2.COMP-Ang1 restored leukocyte-endothelial interaction, retinal oxygenation, vascular density, vascular marker expression, vessel permeability, retinal thickness, inner retinal cellularity, and retinal neurophysiological response to levels comparable with nondiabetic controls. In late DR, AAV2.COMP-Ang1 enhanced the therapeutic benefit of intravitreally delivered endothelial colony-forming cells by promoting their integration into the vasculature and thereby stemming further visual decline. AAV2.COMP-Ang1 single-dose gene therapy can prevent neurovascular pathology, support vascular regeneration, and stabilize vision in DR.

Quality of life and nutritional status in alcohol addicts and patients with chronic liver disease

OBJECTIVE

The aim of the study was to assess and compare the nutritional status and quality of life in chronic liver disease (alcoholic and non-alcoholic) patients and alcohol addicts.

METHODS

Patients with alcoholic liver disease (n=41), nonalcoholic liver disease (n=40), alcohol addicts (n=25) without liver disease and healthy controls (n=25) were randomly selected. Nutritional status was assessed using anthropometric measurements viz. skin fold thickness, arm muscle circumference and area. Biochemical estimations included liver function tests. Food intake was assessed using 48 hour recall and macro-nutrient intake was calculated. Quality of life was assessed using the SF-36 questionnaire.

RESULTS

The mean value of mid-arm muscle area was significantly lower in patients from the non-alcoholic liver disease group when compared with the other 2 groups (p= 0.0). Body fat store depletion was significantly lower in the alcohol addict group when set against the alcoholic liver disease and non-alcoholic liver disease groups (p= 0.0). The mean percentages of ideal calories (p= 0.0) and proteins (p= 0.0) were significantly higher in alcohol addicts but no significant differences in the mean percentage of fat intake (p= 0.1) was observed. The frequency of macro-nutrient deficiency was highest in the non-alcoholic liver disease group (p= 0.0). Ethanol consumption was not significantly different between alcohol addicts and patients suffering from alcoholic liver disease (p=0.06). Patients with liver disease (irrespective of aetiology) scored significantly lower on the quality of life scale when compared to alcohol addicts.

CONCLUSIONS

Malnutrition is more frequent and severe in patients suffering from chronic liver disease in comparison to alcohol addicts. The health status is significantly poorer in patients suffering from alcoholic liver disease. Alcohol does not seem to play a primary role in the pathogenesis of liver disease and malnutrition.

Magnetic loop basket: a "two-in-one" instrument

BACKGROUND AND STUDY AIMS

Ingested coins are the most common foreign bodies encountered in the upper gastrointestinal tract in India and if they remain in the stomach for more than 5 days they need to be removed. Ferromagnetic retrieval instruments only work if the coins are ferromagnetic; and it is difficult to maneuver a loop basket in the fundus of the stomach. A magnetic loop basket was designed in an effort to overcome these difficulties and we assessed its feasibility, safety, and effectiveness in the removal of coins from the fundus of the stomach.

PATIENTS AND METHODS

Twenty patients with a history of ingested coins were scheduled for removal of the coins using the magnetic loop basket. The time taken, complications, and failure rates were recorded.

RESULTS

Twelve ferromagnetic coins were removed in a mean time of 60 seconds (range 30 - 90 seconds) and eight non-ferromagnetic coins were removed in a mean time of 150 seconds (range 90 - 180 seconds) without any failures or complications.

CONCLUSION

The magnetic loop basket is a safe, effective, and quick method for removing both ferromagnetic and non-ferromagnetic metallic coins.

Comparison of nutritional status between patients with alcoholic and non-alcoholic liver cirrhosis

OBJECTIVE

The aim of the study was to assess and compare the nutritional status of alcoholic and non alcoholic cirrhotic patients.

METHODS

81 patients with liver cirrhosis--41 alcoholic (AC) & 40 non alcoholic (NAC), were selected. Nutritional status was assessed using anthropometric measurements viz. skin fold thickness, arm and muscle circumferences and areas. Food intake was evaluated using 48 hour dietary recall. Creatinine Height Index and Lean Body Mass were calculated from 24 hour urinary creatinine excretion.

RESULTS

Mean values of Mid Arm Muscle Area, for both AC and NAC (2947+/-8.12 mm(2) v/s 3534+/-6.96 mm(2) respectively), were below the 5th percentile of Frisancho's cut off, with significant reduction in alcoholics (P = 0.00). Creatinine Height Index (CHI) and Lean Body Mass (LBM) were higher in patients without fluid retention as compared to those with fluid retention. Patients without Ascites showed a positive correlation between body weight and Lean Body Mass (r=0.471; rho=0.438; P=0.00).

CONCLUSIONS

Malnutrition is widely prevalent in cirrhotics, with greater impairment in alcoholics. A positive correlation could be elicited between Lean Body Mass & Actual Body Weight in patients without ascites. Creatinine Height Index and Lean Body Mass may be more reliable parameters for the assessment of nutritional status in patients with liver cirrhosis.

Achalasia cardia: A study of 113 patients managed with indigenous dilator

BACKGROUND

Endoscopic dilatation of achalasia cardia is an effective nonsurgical management option. It requires costly pneumatic dilators which are used under fluoroscopic guidance. This study assesses the efficacy and safety of an indigenous pneumatic dilator used without fluoroscopic guidance.

METHODS

Over a period of eleven years, 113 patients (69M, 44F) ofachalasia cardia underwent dilatation with indigenous pneumatic dilators without fluoroscopic guidance. The dilatation was performed under endoscopic vision.

RESULTS

The procedure was successful in all patients. After six weeks following dilatation, there was significant improvement in the mean dysphagia score 3.63 + 0.61 to 0.53 + 0.93 (P<0.01). The response was still significant (0.78 + 1.03, P <0.05) at the end of one year. Excellent response with single dilatation was seen in 70.7% patients. After two dilatation sessions 92% of patients showed an excellent response. One patient had perforation. There was no mortality.

CONCLUSION

Pneumatic dilatation under endoscopic vision without fluoroscopic assistance with the indigenous dilator is very effective and safe for short term treatment of achalasia carida.

Endoscopic band ligation for non variceal bleed

Endoscopic band ligation (EBL) is an infrequently used modality for treatment of non-variceal hemorrhage. We report the successful use of this technique for the management of bleed from blue rubber bleb nevus syndrome lesions and post polypectomy bleeding stalk.

Improvized pneumatic dilator for achalasia cardia

The indigenous pneumatic dilator for achalasia cardia reported previously by the authors was being placed alongside the endoscope to perform dilatation under direct vision. It has now been improvised to make the procedure wire-guided and fluoroscopy-assisted as well. The improvization includes insertion of a central Teflon tube for passage of a guidewire and presence of three radio-opaque markers, which define the proximal, central and distal ends of the dilator and help in precise positioning under fluoroscopy. Dilatation for achalasia cardia using the improvized pneumatic dilator with fluoroscopic guidance was performed successfully on 10 patients at our center. All patients had clinical response with greater than 50% improvement in total symptom score. Barium swallow examination after dilatation showed improvement in esophageal transit in all patients. None of the patients developed any complication. Cost of the dilator is approximately 50 times less than that of commercially available dilators. The dilator can be re-used by sterilizing it, which further reduces the cost.

Seroepidemiology of hepatitis A infection in India: changing pattern

OBJECTIVE

Recent changes in the epidemiology of hepatitis A virus (HAV) infection and the availability of effective vaccines have renewed interest in this infection. We determined the age-related prevalence of anti-HAV antibodies in India and looked for differences by known risk factors for HAV infection.

METHODS

In this prospective study, serum samples obtained from 1612 subjects aged 1 to 60 at six centers in five cities (Calcutta, Cochin, Indore, Jaipur and Patna) during the period February to August 1998 were tested for anti-HAV antibodies. Demographic and socio-economic information was obtained by questionnaire.

RESULTS

The overall seroprevalence rate was 65.9%, varying from 26.2% to 85.3% in various cities; there was no difference between males and females. Seropositivity increased with age from 52.2% in the 1-5 year age group to 80.8% in those aged 16 years or more. Seroprevalence rates were significantly lower in those aged 1-5 years compared with other age groups (p<0.0001). There was no difference in seroprevalence between those with monthly family income <Rs 5000 and >Rs 5001. Multivariate analysis showed that anti-HAV seroprevalence varied significantly by source of water supply, being highest when the supply was municipal.

CONCLUSION

Our results indicate an epidemiological pattern of intermediate endemicity. This finding has public health implications as it indicates that a significant proportion of the Indian adolescent and adult population is at risk of HAV infection.

Evaluation of garlic oil as a contact dissolution agent for gallstones: comparison with monooctanoin

AIM

To find a better contact solvent to dissolve gallstones we studied invitro use of garlic oil and compared it with monooctanoin.

METHODS

In the first stage gall stones obtained from patients after cholecystectomy were subjected to dissolution in different concentrations of garlic oil. Then the rate of dissolution of gall stones in garlic oil was compared to that in monooctanoin in stage II. Efficacy of various concentration of garlic oil and monoocatanoin in dissolving gallstones in artificial gall bladder and common bile duct models were compared in stage III.

RESULTS

Garlic oil dissolved the cholesterol gall stones in proportion to the concentration used. The gall stone fragmentation was faster [6 hours V/s 36 hours] and more [88.30% V/s 71.01%] by garlic oil in comparison to monooctanoin in test tubes and even in artificial gallbladder and common bile duct models.

CONCLUSIONS

Garlic oil is a better contact dissolving agent of gallstones than monooctanoin.

Primary aortoesophageal fistula: presenting as massive upper gastrointestinal hemorrhage

Primary aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding. A six-year-old boy presented with massive upper gastrointestinal hemorrhage. Endoscopy revealed a submucosal bulge in the esophagus with an ulcer and clot at the top. Lateral skiagram of the chest showed a posterior mediastinal mass. CT scan of the chest revealed a ruptured aortic aneurysm into the oesophagus, confirmed the diagnosis. The patient succumbed to the illness before he could be subjected to definitive treatment.

Unusual foreign bodies of upper gastrointestinal tract

We report management of unusual foreign bodies of upper gastrointestinal tract, namely beer bottle cap, raisins and pistachu, mango peel, betelnut and plum seed at a university hospital in Northern India.

Endoscopic variceal ligation in children

Endoscopic variceal ligation, a mechanical mode of variceal obliteration, was used in the management of patients having extrahepatic portal vein obstruction. Fifteen patients (10 males, 5 females) had grade III varices. Their mean age was 8.13 years (range, 3 to 14 years). Obliteration was achieved in 14 patients (93.33%) after a mean number of 1.86 (range, 1 to 4) sessions. The mean number of bands required for variceal obliteration was 4.33 (range, 1 to 9). The number of bands required to obliterate each variceal column was 1.38. No patient required a blood transfusion, and there was only one recurrence of varices during the mean follow-up period of 9 months (range, 4 to 12 months). Postligation hemorrhage was encountered in one patient; there was no other complications. Endoscopic variceal ligation is an effective and safe method for early variceal obliteration in children.

Pneumatic dilatation of achalasia cardia with indigenous pneumatic dilator

Fifteen patients with achalasia cardia underwent pneumatic dilatation using an indigenous pneumatic dilator. The dilator was prepared using a Levin's tube, latex condoms and silk cloth and was introduced under vision with the help of an endoscope. Clinical improvement was seen in all the patients whereas radiological improvement occurred in 11 patients. There were no procedure-related complications.

Colonoscopy for unexplained lower gastrointestinal bleeding in a tropical country

Two hundred and forty consecutive patients with recurrent lower gastrointestinal bleeding were studied by colonoscopic examination. These included 187 adults and 53 children. The procedure was successful either in identifying the lesion or in excluding it up to the cecum in 216 (90% patients). The source of bleeding was identified in 138 (74%) adults and 43 (81%) Children. Predominant lesions in adults were nonspecific colitis and ulcers (58%), polyps (19%), cancer (10%), rectal varices (4%) and tuberculosis (3%). Juvenile polyps (77%) and nonspecific colitis and ulcers (23%) were the cause of bleeding in children. Both in adults and children, 92% of these lesions involved the left colon. Rectum and sigmoid colon were mainly involved. Diffuse lesions were seen when nonspecific colitis and ulcers were the source of bleeding. Thus colonoscopic examination was useful in localizing the cause of rectal bleeding and the predominant lesions were different from those reported in the Western hemisphere.

Jejunal perforation: a complication of colonoscopy

Perforation of a hollow viscus following fibreoptic endoscopy is rare. Perforation following colonoscopy has been reported to occur in the large intestine. We report a case. Small bowel perforation subsequent to colonoscopy.

Psychological and sociodemographic correlates of the irritable bowel syndrome

Thirty patients with the Irritable Bowel Syndrome (IBS) were evaluated for personality profiles and psychiatric morbidity. In comparison with normal controls, these patients were more neurotic, showed more anxiety and had a higher incidence of neurotic depression, anxiety neurosis and alcoholism. IBS was found to be more common in young, urban males and sedentary workers.

Endoscopic variceal ligation: an effective method of variceal obliteration

Endoscopic variceal ligation was performed in 20 patients with portal hypertension of varied etiology. Variceal obliteration was achieved in 18 patients (90%) while recurrence of bleeding occurred in two patients (10%). The average number of bands required was four per patient and average number of sessions required for variceal obliteration was two. We found the procedure to be cheap, safe and effective in achieving early variceal obliteration.

Endoscopic sclerotherapy: treatment of choice in patients less than 3 years old with extrahepatic portal vein obstruction

Thirty-two children under 3 yr of age with extrahepatic portal vein obstruction were treated with endoscopic sclerotherapy. The group consisted of 22 males and 10 females, with a mean age of 1.96 yr (range 7 months to 3 yr). The procedure was well tolerated by all after premedication with intravenous diazepam. Esophageal varices were eradicated in all children after 4.45 sessions (+/- 1.12). Follow-up clinical and endoscopic evaluations have been carried out over a period of 9 months to 4 yr (mean 3.5 yr) after the patients were put on a sclerotherapy program. There was a significant reduction in number of bleeding episodes (60 vs. 8), mean blood transfusion requirement (2.19 vs. 0.31), and bleeding risk factor (0.09 vs. 0.008). There were a few minor conditions, such as transient dysphagia and esophageal ulcerations, in 14 patients (43.75%), which later responded to medical treatment. Perisclerotherapy bleeding, seen in six patients (18.7%), responded to repeat sclerotherapy. Recurrence of varices was encountered in two patients (6.25%); these were eradicated after reinstitution of sclerotherapy. Endoscopic sclerotherapy is the treatment of choice in patients of extrahepatic portal vein obstruction who are below 3 yr of age.