Robust implementation of school food policy is needed to improve nutritional outcomes of children in European and Western Pacific countries: A systematic review

OBJECTIVE

The present systematic review explored compliance status with school food policies in Europe and the Western Pacific regions, challenges and facilitators of policy compliance, and its impact on children's diets and nutrient intakes.

RESEARCH METHODS

An electronic search for full-text research articles published between January 2009 and July 2023 was conducted in Science Direct and PubMed scientific databases.

RESULTS

A total of 659 titles and abstracts were screened, and final data was extracted from 34 included studies. Results showed low compliance with the school food policy in Europe and the Western Pacific regions. The European schools chad better compliance than the Western Pacific, and supportive interventions improved policy adherence. Impact assessment studies reported that the implementation of the school food policy increased fruit and vegetable consumption, thus increasing nutrient intakes (vitamin A, vitamin D, iron, calcium, folate, and dietary fibers). However, its impact on the availability and consumption of foods high in fat, sugar, and salt (HFSS) was less conclusive. The effects of the policy on the school food environment indicated no significant improvement.

CONCLUSION

Results highlighted the need for additional support and surveillance at the school level to ensure adequate policy compliance.

A critical comparison of the Indian school food and nutrition guidelines with the WHO-nutrition friendly school initiative and the review of existing implementation scenario

Background: The school-based food and nutrition guidelines approach has the potential to combat undernutrition, overnutrition and micronutrient deficiencies among children and adolescents and set the foundation for a healthy adult lifestyle. Aim: To critically compare the Nutrition Friendly School Initiative (NFSI) of the World Health Organization (WHO) with the Food Safety and Standards Authority of India (FSSAI) and the Indian Academy of Pediatrics (IAP) guidelines to gauge the strengths and limitations. Additionally, to summarize the existing studies on implementing school food and nutrition guidelines. Methods: Policy documents of the above guidelines were critically evaluated, and narrative analysis was conducted. An electronic search was conducted for full-text research articles published in the English language between January 2007 to September 2021 in Science Direct, PubMed, Web of Science, and SCOPUS databases. Results: Upon critical comparison of the three guidelines, it was found that the NFSI and FSSAI guidelines shared similarities in many components and the FSSAI guidelines, if implemented adequately, could improve the school food environment and combat the triple malnutrition burden in India. After screening the articles based on the eligibility criteria, 11 studies were included in the preparation of the review. Studies reported partial or inadequate implementation and poor compliance with the guidelines or approach. A few studies identified barriers to guideline implementation. Conclusion: Implementation of school food and nutrition guidelines could improve the nutritional outcomes in children and adolescents. To sustain the effective implementation, adequate resources and preparedness are essential in low-and middle-income countries, including India.

Evaluation of factors predicting response to abiraterone acetate in metastatic castration-resistant prostate cancer: A prospective study

Background/Objectives:

In the current era, abiraterone acetate is mainstay of the treatment strategies of castration-resistant prostate cancer and proven to prolong overall survival. We aimed to prospectively identify factors associated with duration of response to abiraterone.

Patients and methods:

All metastatic castration-resistant prostate cancer patients eligible for abiraterone were included in the study from February 2019 till March 2020. All baseline data and potential factors associated recorded and follow-up with prostate-specific antigen (PSA), and required investigations were done at 1 month interval. Duration of PSA response was recorded, and patients were divided in five groups on the basis of duration of response. Univariate and multivariate analyses of potential factors were done, and data analysis was done with SPSS (Statistical Package for the Social Sciences) version 21.0.

Results:

In this study, after univariate analysis, seven factors were associated with longer duration of response to abiraterone. These were PSA at diagnosis (hazard ratio (HR) = −1.011 (95% confidence interval (CI) = 1.003–1.020), p-value = 0.008), PSA at start of abiraterone (HR = −1.018 (95% CI = 1.011–1.025), p-value = 0.0001), nadir PSA (HR = −1.063 (95% CI = 1.024–1.104), p-value = 0.001), prostate-specific antigen doubling (PSAD) time (HR = −0.745 (95% CI = 0.672–0.827), p-value = 0.001), raised alkaline phosphatase (ALP) (HR = −1.002 (95% CI = 1.001–1.003), p-value = 0.001), neutrophil/lymphocyte ratio (NLR) (HR = −2.16 (95% CI = 1.672–2.81), p-value = 0.001) and <5 bone metastasis (HR = −0.235 (95% CI = 0.130–0.422), p-value = 0.01). But after multivariate analysis, nadir PSA achieved, PSAD, NLR and ⩽5 bone metastasis were predictors of better response to abiraterone.

Conclusion:

This study had identified that less nadir PSA achieved, long PSAD time, low NLR and limited number of skeletal metastases were potential factors for better PSA response to abiraterone.

Level of evidence:

1

Association between vitamin D deficiency and prostate cancer: Prospective case-control study

Objective:

We aimed to find out the association of low serum vitamin D levels with the incidence of prostate cancer through a prospective case-control study.

Material and methods:

This study was carried out in the tertiary care hospital (India). All newly diagnosed patients of prostate cancer and age-matched controls were included. Serum vitamin D levels were measured in all of them. Vitamin D status (ng/mL) was classified as severe deficiency <10, moderate deficiency 10–<30, normal 30–100, and toxicity >100. Normality of the data was tested by the Kolmogorov–Smirnov test, statistical analysis was done with Statistical Package for the Social Sciences version 26.0, p-value of <0.05 was considered significant.

Results:

In our study, 320 cases and 320 controls were included. The mean vitamin D levels in cases and controls were 15.71 ± 6.5 (ng/mL) and 17.63 ± 4.54 (ng/mL), respectively, ( p-Value <0.01). Patients with severe vitamin D deficiency (73.58%) had a Gleason score ⩾8 on biopsy and 79.24% of them had a serum prostate specific antigen (PSA) level >20 ng/mL.

Conclusion:

We had concluded that there was no significant association between vitamin D deficiency and increased risk of prostate cancer, although patients with higher-grade prostate cancer and with higher PSA level had severe vitamin D deficiency.

Level of evidence:

Not applicable for this multicentre audit.

Nutritional Quality of Canteen Foods and Knowledge, Attitude and Practice of Food Handlers in Health Promoting and Non-Health Promoting Private Secondary Schools of Pune City

Objectives

To assess the nutritional quality of foods served in school canteens and Knowledge, Attitude and Practices of food handlers in Health Promoting and Non-Health Promoting Private Secondary Schools of Pune City, India.

Methods

A cross-sectional study was conducted in school canteens of the private secondary schools, Pune City. Out of 316 private schools in the city, 32 private secondary schools with on-campus canteen facilities. All food handlers (n = 64) directly involved in food service were interviewed. Data collected included information on different types of foods served in the school canteens, food safety, sanitation and hygiene practices in the school canteens (a scorecard was prepared using FSSAI guidelines to assess school canteens' food safety, Sanitation and Hygiene of school canteens), and knowledge, attitude and practice (KAP) of food handlers on food quality, food safety and Food Safety and Standards Authority of India's (FSSAI) guidelines (a structured pre-tested questionnaire). The nutritional quality of foods served in school canteens was assessed using High Fat Sugar and Salt (HFSS) cut-offs of the FSSAI as healthy and unhealthy.

Results

Out of 32 schools, 25 were Non-Health Promoting (NHPS), and seven schools followed Health Promoting (HPS) concept. HPS had significantly higher provision for healthy food items than non-HPS (87.4% vs 46.2%; p &lt; 0.001). The HPS effectively reduced high-fat foods from the menu (p = 0.03), however reduction in sugar and salt products was not sufficient. Food handlers from the HPS category had higher knowledge to identify healthy foods from the school menu (p &lt; 0.001) and had a better attitude towards healthy foods for school children (p ≤ 0.04). There was no significant difference in food safety practices of food handlers; however, HPS followed safer methods for serving foods (p &lt; 0.001). A few participants from both the school categories had attended any nutrition training program for food handlers (30% for HPS vs 25% Non-HPS; p = 0.68).

Conclusions

A few private secondary schools implemented the HPS initiative in Pune City, which positively influenced the school food environment by introducing healthy foods and improved attitudes among food handlers towards healthy foods in school canteens.

Funding Sources

The study was not funded.

Seed size dimorphism in Hyptis suaveolens aids in differentiation of the germination niche

Seed germination characteristics help predict the degree of invasive success of a species based on capacity of the seeds to germinate and recruit into novel habitats. Hyptis suaveolens (L.) Poit. (Bush mint, Pignut; Lamiaceae) is an invasive plant that is spreading throughout tropical and subtropical regions worldwide. We conducted a study to understand the role of seed size dimorphism in differentiation of germination niche in H. suaveolens. We subjected small and large seeds to varying environmental conditions of temperature (°C), photoperiod (light/dark), salt (NaCl; mM), pH, osmotic potential (MPa), different soil types and ratios (clay:sand) and burial depth (cm). Different germination indices were calculated and their interaction with seed dimorphism studied. There was a significant interaction (P < 0.001) between germination indices and seed dimorphism throughout the treatments. Large seeds had higher germination percentage and rate, indicating higher germination capacity. In addition, these displayed more asynchronous germination under various environments. Small seeds, on the other hand, required a longer germination time as compared to large seeds, indicating slower germination. Differential responses of the two seed morphs to varying environmental conditions, therefore, help H. suaveolens to differentiate its germination niche and establish in heterogeneous environments. These findings will help in devising appropriate management and eradication strategies based on germination ecology of seeds.

Review on anticancerous therapeutic potential of Withania somnifera (L.) Dunal

ETHNOPHARMACOLOGICAL RELEVANCE

Withania somnifera, commonly known as Ashwagandha, is an important medicinal herb belonging to family Solanaceae. It is widely used in folkloric and Ayurvedic medicines since antiquity. Traditionally, the plant is highly practiced throughout the globe as immunomodulator, anti-inflammatory, anti-stress, anti-parkinson, anti-alzheimer, cardio protective, neural and physical health enhancer, neurodefensive, anti-diabetic, aphrodisiac, memory boosting etc. The plant is also effective in combating various types of cancer and other related problems of colon, mammary, lung, prostate, skin, blood, liver and kidney.

AIM OF THIS REVIEW

The present review represents the critical assessment of the literature available on the anticancerous role of W. somnifera. The present study throws light on its diverse chemical compounds and the possible mechanisms of action involved. This review also suggests further research strategies to harness the therapeutic potential of this plant.

MATERIALS AND METHODS

The present review is the outcome of a systematic search of scientific literature about 'Withania somnifera and its role in cancer prevention'. The scientific databases viz. Google Scholar, Science Direct, Pubmed and Web of Science were searched from 2001 to 2019. Textbooks, magazines and newspapers were also consulted. This review summarizes all the published literature about its therapeutic potential for the treatment of different types of cancers.

RESULTS

W. somnifera has been widely used in traditional and ayurvedic medicines for treatment of numerous problems related to health and vitality. The plant is a reservoir of diverse phytoconstituents like alkaloids, steroids, flavonoids, phenolics, nitrogen containing compounds and trace elements. Withanolides are the major alkaloids which renders its anticancer potential due to its highly oxygenated nature. The plant is highly effective in combating various types of cancers viz. colon, mammary, lung, prostate, skin, blood, liver and kidney. Previous studies depict that this plant is more effective against breast cancer followed by colon, lung, prostate and blood cancer. Furthermore, from different clinical studies it has been observed that the active constituents of the plant like withaferin-A, withanolide-D have least toxic effects.

CONCLUSION

The present review confirms the various medicinal values of W. somnifera without any significant side effects. Withaferin-A (WA) and Withanolides are its most promising anticancer compounds that play a major role in apoptosis induction. Keeping in mind the anticancerous potential of this plant, it is suggested that this plant may further be investigated and more clinical studies can be performed.

Crossed complete fused left to right renal ectopia with solitary left ureter: A rare ‘Case Report’

Background

Crossed fused renal ectopia is a rare congenital anomaly where both the kidneys are fused and situated on one side and drain bilaterally into the urinary bladder. Rarely crossed fused ectopia can present with a single ureter draining ipsilaterally into the bladder, but here we are presenting for the first time a rare case of right crossed fused ectopia, where a solitary ureter crosses midline and drains contralaterally into the bladder.

Case presentation

A 19-year-old adolescent male patient presented with intermittent chronic right flank pain for 3 months. General physical and per abdominal examinations were normal. Computerized tomography (CT) urography showed right side crossed fused ectopic kidneys with a solitary ureter draining both the kidneys and opening into the left side of the urinary bladder. The patient was managed conservatively and is on regular follow-up.

Conclusion

Crossed complete renal fused ectopia with solitary contralateral ureteral is a rare case. Individualized case-based management is needed depending upon the symptoms, associated anomalies, and pathology. Reporting of all rare congenital cases will help in the future understanding and management of these conditions.

A comprehensive review on ethnomedicine, phytochemistry, pharmacology, and toxicity of Tephrosia purpurea (L.) Pers

Tephrosia purpurea (L.) Pers. is a well-known plant in Ayurveda and named "Sarwa wranvishapaka" for its property to heal wounds. Traditionally, it is practiced for impotency, asthma, dyspepsia, hemorrhoids, syphilis gonorrhea, rheumatism, enlargement of kidney and spleen. It is an important component of herbal preparations like Tephroli and Yakrifti used to cure liver disorders. Various phytocompounds including pongamol, purpurin, purpurenone, tephrosin, bulnesol, tephrostachin, β-sitosterol, and so on have been reported. Modern pharmacological studies have shown that the plant have wound healing, antileishmanial, anticarcinogenic, antimicrobial, antioxidant, hepatoprotective, antifertility, antispermatogenic, anti-diarrheal, diuretic, and insecticidal properties. Acetylcholinesterase inhibitory action reported from this plant aids its utilization for the development of drugs for Alzheimer's and dementia neurological disorders. Among the known active compounds of T. purpurea, tephrostachin is responsible for antiplasmodial activity, tephrosin, pongaglabol, and semiglabrin exerts antiulcer activity while quercetin, rutin, β-sitosterol, and lupeol are mainly responsible for its anti-inflammatory and anti-cancer properties. From different toxicological studies, concentrations up to 2,000 mg/kg were considered safe. The present review comprehensively summarizes the ethnomedicine, phytochemistry, pharmacology, and toxicology of T. purpurea. Further research on elucidation of the structure-function relationship among active compounds, understanding of multi-target network pharmacology and clinical applications will intensify its therapeutic potential.

Linguistic and cultural validation of Ureteral Stent Symptom Questionnaire in Hindi

Introduction:

In the year 2003, Joshi et al. developed a validated outcome assessment tool to measure the ureteral stent-related symptoms. The original English language Ureteral Stent Symptom Questionnaire (USSQ) has been validated in various languages worldwide. Our objective was to develop the USSQ in Hindi, a commonlyused language in India, by validating it in patients undergoing ureteroscopic lithotripsy.

Materials and Methods:

A final Hindi version of the USSQ was derived from the original English version to apply to the study population by translation, back translation, and face-to-face interviews. The Hindi and English versions were completed by 70 patients undergoing ureteroscopic lithotripsy with stent in situ, on postoperative days 7 and 8, and 4 weeks after stent removal. Similarly, discriminant validity was checked among 50 healthy individuals. A detailed statistical analysis was used to correlate results (Cronbach's α coefficient, Spearman's correlation, and Mann–Whitney U-test).

Results:

A total of 70 patients were enrolled in the study and 61 completed the final assessment. The median age was 35 years (range: 18–60 years). The USSQ domain scores with the stent in situ were higher than poststent status. The test–retest reliability checked by Cronbach's α coefficient (>0.44) and Spearman's correlation coefficient (>0.44) were acceptable to good. We found high discriminant validity of the questionnaire between patients with stent and the healthy controls (P < 0.05).

Conclusion:

Our results demonstrate satisfactory validity for the Hindi version of the USSQ for the assessment of quality of life in patients with stent. This is ready for application in the clinical studies and the future stent-related research in Hindi language.

Primary Low-Grade Fibromyxoid Sarcoma of Kidney-an Extremely Rare Entity

Renal LGFMS is an extremely rare tumor. So far, only four cases have been reported in literature. LGFMS are indolent tumor with distinctive histopathological features with potential for late recurrences and metastasis. The diagnosis is made on histopathological examination and supported by immunohistochemical analysis. A 35-year-old young male was presented with flank pain and lump and diagnosed as low-grade fibromyxoid sarcoma after surgery on immunohistochemical analysis. This is the fifth case of renal LGFMS and we presented the review of literature. Radical surgery remains the primary treatment modality. Long follow-up is mandatory.

A Comparative Study of Antegrade Air Pyelogram and Retrograde Air Pyelogram for Initial Puncture Access during Percutaneous Nephrolithotomy

INTRODUCTION

Access into the collecting system is considered to be the most critical step for Percutaneous Nephrolithotomy (PCNL).

AIM

The present study provides a comparative view into antegrade air pyelography and retrograde air pyelography procedures for percutaneous renal access.

MATERIALS AND METHODS

A cross-sectional study was conducted on 100 patients with radiopaque renal calculi indicated for PCNL procedure. These patients were randomly assigned to two groups namely antegrade air pyelogram group (Group I) and retrograde air pyelogram group (Group II). In antegrade air pyelogram group, the collecting system was delineated by targeting the renal stone using a 22 gauge spinal needle where the patients were in the prone position. In another group, the collecting system was delineated by retrograde air pyelogram under fluoroscopy guidance. The method of tract dilatation and stone extraction were the same in both groups for comparison of outcome and complication.

RESULTS

The mean age of patients was 41.7±13 and 41.4±13.6 years in Group-I and Group-II respectively. The male to female ratio in Groups I and II was 35/15 (70.00%) and 38/12 (76.00%) respectively. In Group-I the average duration of access was 2.66±1.0 minutes after prone positioning whereas it was recorded to be 19.48±5.0 minutes in Group-II, after lithotomy followed by prone positioning of the patient. Duration of radiation exposure was almost similar in both groups. Additional procedural cost was significantly higher in Group II.

CONCLUSION

Our study indicated that access for PCNL using antegrade air pyelogram can be a cost-effective and acceptable alternative to retrograde air pyelogram with decreased access time.

Purification and characterization of laccase secreted by Phellinus linteus MTCC-1175 and its role in the selective oxidation of aromatic methyl group

A laccase from the culture filtrate of Phellinus linteus MTCC-1175 has been purified to homogeneity. The method involved concentration of the culture filtrate by ammonium sulphate precipitation and an anion exchange chro- matography on DEAE-cellulose. The SDS-PAGE and native-PAGE gave single protein band indicating that the enzyme preparation was pure. The molecular mass of the enzyme determined from SDS-PAGE analysis was 70 kDa. Using 2,6-dimethoxyphenol, 2,2'[azino-bis-(3-ethylbonzthiazoline-6-sulphonic acid) diammonium salt] (ABTS) and 4-hydroxy-3,5-dimethoxybenzaldehyde azine as the substrates, the Kin, kcat and kt/Km values of the laccase were found to be 160 microM, 6.85 s(-1), 4.28 x 10(4) M(-1) s(-1), 42 microM, 6.85 s(-1), 16.3 x 10(4) M(-1) s(-1) and 92 microM, 6.85 s(-1), 7.44 x 10(4) M(-1) s(-1), respectively. The pH and the temperature optima of the P. linteus MTCC-1175 laccase were 5.0 and 45 degrees C, respectively. The activation energy for thermal denaturation of the enzyme was 38.20 kJ/mole/K. The enzyme was the most stable at pH 5.0 after 1 h reaction. In the presence ofABTS as the mediator, the enzyme transformed toluene, 3-nitrotoluene and 4-chlorotoluene to benzaldehyde, 3-nitroben-zaldehyde and 4-chlorobenzaldehyde, respectively.

Bilateral single system ectopic ureters opening into vestibule with bladder agenesis

Almost 80% of ectopic ureters are associated with duplicated system, and 5-17% of ectopic ureters are bilateral. Ectopic ureters usually open into urethra, vestibule and vagina in females and into posterior urethra and seminal vesicles in males. Bilateral single-system ectopic ureter (BSSEU) is a rare entity in urology. BSSEU opening into a vestibule with the absence of urinary bladder is an extremely rare occurrence. We report such a case and briefly discuss its management.

Primary hypoparathyroidism: psychosis in postpartum period

We report a 30-yr-old lady who was being treated as postpartum psychosis. Patient had generalized tonic clonic convulsions and was found to have bilateral cataract. Her serum calcium, serum magnesium and serum parathyroid were low. On correction of serum magnesium her PTH did not increase. She was hence diagnosed as primary hypoparathyroidism. On correction of her serum calcium her psychosis improved.

Sulphur mustard vapor breakthrough behaviour on reactive carbon systems

Breakthrough behaviour of sulphur mustard, the deadliest of persistent chemical warfare agents, on carbon systems such as NaOH/CrO(3)/C, NaOH/CrO(3)/EDA/C and RuCl(3)/C has been studied and the data were compared with that of active carbon. Effects of bed lengths of carbons on breakthrough time have also been correlated. Thereafter, the effects of flow rate of air-sulphur mustard mixture, concentration and temperature on the kinetic parameters such as rate constant (k(v)) and kinetic saturation capacity (W(e)) were analyzed and interpreted by means of modified Wheeler equation. Rate constant was found to be increasing while W(e) was found to be invariable with the increase in air flow rate. Both k(v) and W(e) decreased with the increase of temperature, however, no significant effect on W(e) and k(v) was observed due to concentration change (0.3-0.6 mg/l). The values of kinetic saturation capacity were used to predict the service lives/breakthrough times of carbon beds (when used in filtration systems).

Complete ureteral avulsion

Complete avulsion of the ureter is one of the most serious complications of ureteroscopy. It requires open or laparoscopic intervention for repair. This case report emphasizes its management and presents recommendations for prevention in current urological practice.

Pterocarpus marsupium extract (Vijayasar) prevented the alteration in metabolic patterns induced in the normal rat by feeding an adequate diet containing fructose as sole carbohydrate

Insulin resistance (hyperinsulinaemia) is now recognized as a major contributor to the development of glucose intolerance, dyslipidaemia and hypertension in non-insulin-dependent diabetes mellitus (NIDDM) patients. Sedentary lifestyle, consumption of energy-rich diet, obesity, longer lifespan, etc., are important reasons for this rise (J. R. Turtle, Int J Clin Prac 2000; 113: 23). Aqueous extracts of Pterocarpus marsupium Linn bark (PM), Ocimum sanctum Linn leaves (OS) and Trigonella foenumgraecum Linn seeds (FG) have been shown to exert hypoglycaemic/antihyperglycaemic effect in experimental as well as clinical setting. As no work has been carried out so far to assess the effect of PM, OS and FG on fructose-induced hyperglycaemia, hyperinsulinaemia and hypertriglyceridaemia, we undertook this study to assess whether these extracts attenuate the metabolic alteration induced by fructose-rich diet in rats. Five groups of rats (eight each) were fed chow diet, 66% fructose diet, 66% fructose diet + PM leaves extract (1 g/kg/day), 66% fructose diet + OS leaves extract (200 mg/kg/day) and 66% fructose diet + FG seeds extract (2 g/kg/day) for 30 days. Fructose feeding to normal rats for 30 days significantly increased serum glucose, insulin and triglyceride levels in comparison with control. Treatment with all the three plants extract for 30 days significantly lowered the serum glucose levels in comparison with control group. However, only PM extract substantially prevented hypertriglyceridaemia and hyperinsulinaemia, while OS and FG had no significant effect on these parameters. Results of this study, in addition to previous clinical benefits of PM seen in NIDDM subjects, are suggestive of usefulness of PM bark (Vijayasar) in insulin resistance, the associated disorder of type 2 diabetes; however, OS and FG may not be useful. Though several antidiabetic principles (-epicatechin, pterosupin, marsupin and pterostilbene) have been identified in the PM, yet future studies are required to certify their efficacy and safety before clinical scenario.

Protrusion of bladder mucosa in exstrophy mimicking cloacal exstrophy

An interesting case of bladder exstrophy with protrusion of bladder mucosa mimicking cloacal exstrophy is reported. The child presented with continuous leakage of urine and swelling in the lower abdomen since birth. Before the operation, this was considered to be a variant of cloacal exstrophy.

Disability and handicap among elderly Singaporeans

Singapore's elderly population has been growing rapidly and is expected to constitute more than 25 percent of the total population by the year 2030. The ageing process brings with it a host of health problems. Here the question arises--Are the increasing years of life going to create a high proportion of sick and disabled elderly people, or a rich human resource of healthy senior citizens? Since more women are living longer than men, who would face a higher risk of disability and handicap? These questions are yet to be answered in Singapore. This paper seeks answers to these questions. The study is based on a sample survey of 1209 elderly Singaporeans living in Kampong Glam, Kreta Ayer and Bukit Merah parliamentary constituencies which have some of the highest proportions of the aged population. The results revealed that more than half of the aged had a disability and the rate of disability was significantly higher among the women as compared to the men. More than one-third of the elderly had a handicap and the rate of handicap among the women was twice as much as that among the men. Severity of handicap was directly correlated with age.

Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders

OBJECTIVE

Carotid bifurcation angioplasty and stenting (CBAS) has generated controversy and widely divergent opinions about its current therapeutic role. To resolve differences and establish a unified view of CBAS' present role, a consensus conference of 17 experts, world opinion leaders from five countries, was held on November 21, 1999.

METHODS

These 17 participants had previously answered 18 key questions on current CBAS issues. At the conference these 18 questions and participants' answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus, (prevailing opinion), or divided opinion (disagreement).

RESULTS

Conference discussion added two modified questions, placing a total of 20 key questions before the participants, representing four specialties (interventional radiology, seven; vascular surgery, six; interventional cardiology, three; neurosurgery, one). It is interesting that consensus was reached on the answers to 11 (55%) of 20 of the questions, and near consensus was reached on answers to 6 (30%) of 20 of the questions. Only with the answers to three (15%) of the questions was there persisting controversy. Moreover, both these differences and areas of agreement crossed specialty lines. Consensus Conclusions: CBAS should not currently undergo widespread practice, which should await results of randomized trials. CBAS is currently appropriate treatment for patients at high risk in experienced centers. CBAS is not generally appropriate for patients at low risk. Neurorescue skills should be available if CBAS is performed. When cerebral protection devices are available, they should be used for CBAS. Adequate stents and technology for performing CBAS currently exist. There were divergent opinions regarding the proportions of patients presently acceptable for CBAS treatment (<5% to 100%, mean 44%) and best treated by CBAS (<3% to 100%, mean 34%). These and other consensus conclusions will help physicians in all specialties deal with CBAS in a rational way rather than by being guided by unsubstantiated claims.

Ischemic preconditioning protects the mouse liver by inhibition of apoptosis through a caspase-dependent pathway

A short period of ischemia and reperfusion, called ischemic preconditioning, protects various tissues against subsequent sustained ischemic insults. We previously showed that apoptosis of hepatocytes and sinusoidal endothelial cells is a critical mechanism of injury in the ischemic liver. Because caspases, calpains, and Bcl-2 have a pivotal role in the regulation of apoptosis, we hypothesized that ischemic preconditioning protects by inhibition of apoptosis through down-regulation of caspase and calpain activities and up-regulation of Bcl-2. A preconditioning period of 10 minutes of ischemia followed by 15 minutes of reperfusion maximally protected livers subjected to prolonged ischemia. After reperfusion, serum aspartate transaminase (AST) levels were reduced up to 3-fold in preconditioned animals. All animals subjected to 75 minutes of ischemia died, whereas all those who received ischemic preconditioning survived. Apoptosis of hepatocytes and sinusoidal endothelial cells, assessed by in situ TUNEL assay and DNA fragmentation by gel electrophoresis, was dramatically reduced with preconditioning. Caspase activity, measured by poly (adenosine diphosphate ribose) polymerase (PARP) proteolysis and a specific caspase-3 fluorometric assay, was inhibited by ischemic preconditioning. The antiapoptotic mechanism did not involve calpain-like activity or Bcl-2 expression because levels were similar in control and preconditioned livers. In conclusion, ischemic preconditioning confers dramatic protection against prolonged ischemia via inhibition of apoptosis through down-regulation of caspase 3 activity, independent of calpain-like activity or Bcl-2 expression.

P-Selectin mediates reperfusion injury through neutrophil and platelet sequestration in the warm ischemic mouse liver

Hepatic damage following ischemia-reperfusion injury involves polymorphonuclear leukocytes (PMN) and platelet sequestration, however the mechanisms of adhesion remain elusive. In this study, using gene-targeted deficient mice, we evaluated P-selectin and its contribution to PMN and platelet adhesion in hepatic damage. In an in vivo warm ischemia model, hepatic injury was assessed by serum transaminase levels, survival, PMN adhesion by histological analysis, and platelet sequestration by immunostaining. Serum transaminase levels were strikingly reduced (by up to threefold) in the P-selectin deficient mice, particularly at 90 minutes of ischemia, when compared with wild-type controls. PMN adhesion and platelet sequestration was also significantly decreased in P-selectin deficient mice following 90 minutes of partial ischemia. Animal survival was significantly improved after 75 minutes of total hepatic ischemia in P-selectin deficient mice when compared with wild-type mice. Survival was also achieved after 90 minutes of ischemia in the mutant mice whereas none of the wild-type animals survived. These data show that P-selectin plays a critical role in PMN and platelet adhesion following ischemia-reperfusion injury to the liver.

L-selectin and ICAM-1 mediate reperfusion injury and neutrophil adhesion in the warm ischemic mouse liver

Leukocytes recruited during ischemia-reperfusion to the liver are important mediators of injury. However, the mechanisms of leukocyte adhesion and the role of adhesion receptors in hepatic vasculature remain elusive. L-selectin may critically contribute to injury, priming adhesion for later action of intercellular adhesion molecule-1 (ICAM-1). Paired experiments were performed using mutant mice (L-selectin -/-, ICAM-1 -/-, and L-selectin/ICAM-1 -/-) and wild-type mice (C57BL/6) to investigate leukocyte adhesion in the ischemic liver. Leukocyte adhesion and infiltration were assessed histologically. Aspartate aminotransferase levels were significantly reduced (2- to 3-fold) in mutant vs. wild-type mice in most groups but most significantly after 90 min of partial hepatic ischemia. Leukocyte adhesion was significantly reduced in all mutant mice. Areas of microcirculatory failure, visualized by intravital microscopy, were prevalent in wild-type but virtually absent in L-selectin-deficient mice. After total hepatic ischemia for 75 or 90 min, survival was better in mutant L-selectin and L-selectin/ICAM-1 mice vs. wild-type mice and ICAM-1 mutants. In conclusion, L-selectin is critical in the pathogenesis of hepatic ischemia-reperfusion injury. Poor sinusoidal perfusion due to leukocyte adhesion and clot formation is a factor of injury and appears to involve L-selectin and ICAM-1 receptors.

A new and simple technique of total hepatic ischemia in the mouse

BACKGROUND

A model of total hepatic ischemia is currently not available in mice. Models described in rats using portosystemic shunts to achieve total ischemia have been notoriously difficult. In mice, the problem is compounded further when using this type of technique because of the small size of the animal. A new technique is described combining partial hepatectomy with clamping of the remnant liver.

METHODS

A partial (30%) hepatectomy is performed with resection of the caudate, right lateral, and quadrate lobes, and papillary process. Vascular microclamps are placed across the pedicles of the median and left lateral lobe at the level of the hilum to achieve total ischemia. Spontaneous portocaval shunts through caudate branches and collateral vessels prevent mesenteric congestion. Animals were studied for survival.

RESULTS

The procedure consistently took less than 30 min (25+/-2 min), and no bleeding of the resected tissue was observed. Evidence for total hepatic ischemia and spontaneous shunts was demonstrated by the use of an intraportal dye. All animals survived 60 min of ischemia, whereas all died after 90 min of ischemia.

CONCLUSION

This is a technically simple and rapid procedure to perform. In the current environment of multiple knockout mice and bioreagents that are available, a model of this type is essential.

Elective carotid artery stenting in the presence of contralateral occlusion

Significant carotid stenosis in the presence of an occluded contralateral artery has a poor prognosis with medical therapy alone. Carotid cross clamping during surgical endarterectomy results in critical flow reductions in patients with inadequate collateral flow, and represents a significant risk for procedural strokes. Carotid stenting is being evaluated as an alternative to endarterectomy. We describe the immediate and late outcome of a series of 26 patients treated with carotid stenting in the presence of contralateral carotid occlusion. The mean age of the patients in this group was 65 +/- 9 years, 23 (89%) were men and 10 (39%) were symptomatic from the vessel treated. The procedural success of carotid stenting in this group of patients was 96%. The mean diameter stenosis was reduced from 76 +/- 15% to 2.8 +/- 5%. There was 1 (3.8%) minor stroke in a patient who developed air embolism during baseline angiography. At late follow-up there was no neurologic event in any patient at a mean of 16 +/- 9.5 months after the procedure. Thus, carotid stenting of lesions with contralateral occlusion can be performed successfully with a low incidence of procedural neurologic complications and late stroke.

Palmaz stent compression in patients following carotid artery stenting

Carotid artery stenting is being investigated as a therapeutic strategy for the management of bifurcation stenosis. Palmaz stents were deployed successfully in the carotid arteries of 112 patients using high-pressure balloon inflations. In 11 out of 70 patients who came for 6-mo follow-up angiography, a stent collapse was noted. Carotid ultrasound was able to detect stent collapse in only two patients at follow-up. Only one patient who had collapse of stent along its entire length was symptomatic at follow-up. Repeat balloon angioplasty was performed in 5 patients, 3 of whom had a Wallstents deployed within the Palmaz stent.

CONCLUSION

Stent collapse was observed in a significant number of Palmaz stents within 6 mo of placement in the carotid arteries. These observations should influence the choice of stents for the treatment of extracranial carotid disease.

Utilization of the coronary balloon-expandable coil stent without anticoagulation or intravascular ultrasound

BACKGROUND

The balloon-expandable coil stent has been proved effective in the management of acute and threatened closure after coronary balloon angioplasty and has been shown to reduce restenosis in patients with suboptimal results after coronary balloon angioplasty. Coronary artery stenting has been limited by the occurrence of stent thrombosis and comorbidity related to anticoagulation. This study was undertaken to determine whether anticoagulation may be removed from poststenting protocols, thus reducing comorbidity without increasing stent thrombosis.

METHODS AND RESULTS

Between September 1994 and May 1995, 369 patients received balloon-expandable coil stents in native coronary arteries at our institution. Of these patients, 216 were selected for a protocol of aspirin and ticlopidine (for 1 month) without anticoagulation. Eligibility for this protocol followed satisfaction of certain procedural and angiographic criteria. These criteria included adequate coverage of intimal dissections, absence of residual filling defects, and normal (TIMI grade 3) flow in the stented vessel after high-pressure balloon inflations. Intravascular ultrasound was not used to guide stent deployment. The stenting procedure was planned in 37% of patients and unplanned in 63% of patients, including 25 (12%) for acute or threatened closure. During the 30-day follow-up period, stent thrombosis occurred in 2 patients (0.9%), there was 1 death (0.5%), and 2 patients (0.9%) underwent coronary bypass surgery. Vascular access-site complications occurred in 4 patients (1.9%), and bleeding that required blood transfusion occurred in 4 patients (1.9%).

CONCLUSIONS

Patients who receive the coronary balloon-expandable coil stent with optimal angiographic results without intravascular ultrasound guidance can be managed safely with a combination of aspirin and ticlopidine without anticoagulation.

Double oblique diaphyseal osteotomy. A new technique for lengthening deformed and short lower limbs

We treated 25 patients with severely deformed and shortened lower limbs by double oblique diaphyseal osteotomy of the short deformed bone, followed by balanced skeletal traction to correct the alignment and increase the length of the limb. The technique is simple and inexpensive and does not require special equipment. It has the advantage of allowing rapid lengthening and secure healing as the overlap allows end-to-end union with no bone gap. The lengthening achieved ranged from 6 to 16 cm. No serious complications were encountered.

Nephrolithiasis in children

A study of 100 cases of nephrolithiasis between 3 to 15 years of age is reported. Seventy four cases were more than 10 years old. The common presenting symptoms included abdominal pain (69%), burning micturition (23%), gross hematuria (4%) and unexplained pyrexia (6%). Associated urinary tract malformations were found in 16 cases. Twenty four had struvite calculi. Urinary infection with Proteus mirabilis was found in 23 children and idiopathic hypercalciuria in 31 cases. Following surgical removal, either percutaneously or by open surgery, 8 patients had residual calculi and in 6 cases recurrence occurred.

Patterns of erythropoiesis and anaemia in leprosy

A total of 128 leprosy patients were investigated for the morphological type of anaemia, the underlying disturbances in iron metabolism and patterns of erythropoiesis and other cytomorphological changes in the bone marrow. The anaemia was a mild to moderate degree in paucibacillary (PB) leprosy, while in multibacillary (MB) leprosy it was of a severe degree. Iron deficiency was observed in only a few patients. Impaired iron utilization as observed in a anaemia of a chronic disorder was a common finding in MB leprosy (41.7%) and more so in new cases (50%). Megaloblastic erythropoiesis was also more frequent in MB leprosy (45.2%) as compared to PB leprosy (16%), accounting for the severe degree of anaemia in the former type. In 17.2% of the total patients (MB, 21.4%; PB, 9%) both megaloblastic erythropoiesis and features of impaired iron utilization were observed in bone marrow. Disturbances in iron metabolism and erythropoiesis were also observed but to a lesser degree in patients receiving specific antileprosy treatment. Irrespective of the type of disease and duration of treatment, increasing frequency of acid-fast bacillia (AFB) positivity and granulomas was observed in the bone marrow with an increasing severity of anaemia.

Tuberculosis of breast (study of 7 cases)

Seven cases of tuberculosis of breast are presented. The clinical features were multiple discharging sinuses, lump, ulcer and recurring abscess of breast. Diagnosis relied on histological appearance. Acid fast bacilli being present in only one specimen and positive culture obtained in one patient. Successful treatment combines antituberculous drug therapy with removal of infected breast tissue.

Surgical management of malignant bone tumours

Limb-salvage surgery has proved adequate in the management of malignant bone tumours. The goal of radical resection is to achieve local control with an appropriate surgical margin. Sixty-five cases of bone tumours have been managed by radical resection and suitable reconstruction by autologous fibular strut grafting. Single fibular grafting was attempted in the upper extremity and dual fibular grafting in the lower extremity. None had obvious evidence of secondary metastases at the time of surgery. out of 65 cases, 39 were sarcomatous lesions. Biplane Angiography had proved extremely useful in the exact delineation and appropriate resection of such lesions. Twenty two patients had complications - eight had local recurrence, three had deep infection needing amputation and eleven had multiple secondaries and died. It is suggested that in an Oncologically sound limb, salvage procedure with biological reconstruction should be attempted.

Dual-fibular grafting for massive bone gaps in the lower extremity

Fifty-two patients who had a tumor in the lower extremity (thirty-seven, a giant-cell tumor and fifteen, a small osteosarcoma that had not metastasized) had dual-fibular strut-grafting to bridge the osseous gap resulting from excision of the tumor. The size of the gap ranged from nine to twenty-four centimeters. The average time until union ranged from ten to twenty months. The ipsilateral fibula was used in thirty-six patients and both fibulae, in the remaining sixteen patients. Immediate reimplantation and adequate fixation of the fibular graft to the proximal and distal ends of the bone to be grafted, along with placement of a cuff of cancellous bone at the host-graft junction and between the fibular struts, fostered early union of the graft to the host bone. Insertion of Kirschner wires inside these long grafts helped to maintain continuity of the graft when a stress fracture occurred. Eight patients who had a non-union at one of the host-graft sites and three who had a stress fracture had subsequent cancellous bone-grafting to obtain union. Superficial infection was the most common complication and was seen in seventeen patients.

Successful treatment of cryptococcal ventriculoatrial shunt infection with systemic therapy alone

We report successful treatment of a cryptococcal ventriculoatrial shunt infection with antifungal therapy without shunt removal.

A Rare Case of Phaeohyphomycosis Caused by Exophiala Jeanselmei

An outbreak of black piedra affected 60% of inmates of a women's hostel. One of the inmates who had piedra even before joining the hostel appears to be the source of infection. Use a common comb for dressing the hair and sharing of pillows and bed sheets while sleeping were the probable factors for spread of the disease. An indigenous treatment that consisted of daily exposure of the affected hairs to steam for 20 minutes was found to be beneficial.

Girdlestone arthroplasty

A series of 92 patient who underwent excision arthroplasty of the hip (Girdlestone arthroplasty) as a primary procedure is presented. The operation was performed for various conditions which included femoral neck fracture, rheumatoid arthritis, ankylosing spondylitis, tuberculosis, septic arthritis, unreduced posterior dislocation of long duration, fracture of the acetabulum, avascular necrosis of femoral head and bony ankylosis. Excision of head and neck of the femur was found to be an excellent salvage procedure for infected hips especially yielding uniformly satisfactory results at all ages irrespective of the disease. It provided a painless, mobile hip. Except for shortening and unstable gait, no other handicap was observed; the disadvantages of this handicap were outweighed by its advantages, compared with the disadvantages of other sophisticated hip operations such as replacement, and mould arthroplasties or even total hip replacement. Our results were excellent in 21% of cases, good in 44% and fair in 26% while they were poor in 9%. In view of its functional end results, we feel that this measure can be a good alternative to more modern and sophisticated hip operations in the form of partial or total hip replacement under Indian conditions.

A rare finger injury

A closed injury of the left index finger displacing the skeleton out of its soft tissue bed is reported. Reduction of the displaced segments in place resulted in normal function of the finger.

Ankle stability after resection of the distal third of the fibula for giant-cell lesions: report of two cases

Giant-cell tumors and aneurysmal bone cysts involving the lower end of fibula pose special management problems. Excision of the lower end of the fibula in such cases is undertaken reluctantly because it may result in lateral instability of the ankle. Two cases, one of giant-cell tumor and one of aneurysmal bone cyst of the lower end of the fibula, were excised and the lateral ligaments of the ankle and the periarticular tissue were carefully repaired. In both patients the ankle joints were stable two years after the operation.