Replication study identified EFEMP1 association with varicose vein predisposition among Indians

BACKGROUND

Varicose vein is a chronic condition that affects the lower extremities of the human body. Several factors have been implicated in the development of this disease, viz age, gender, weight, height and prolonged standing. Recently, genome-wide studies have identified genetic biomarkers that are associated with varicose veins in different ethnic groups. Such genetic studies are lacking in South Asians specifically in Indians where the prevalence of varicose veins is high, and it is important to replicate these variants in the stated population. The study aimed to replicate the association of genetic variants associated with varicose veins in this target population, which were found to be associated with the other ethnic groups.

METHODOLOGY

The studied cohort is of the Indian population comprising unrelated 104 varicose veins cases and 448 non-varicose vein controls. The samples were genotyped using the Illumina Global Screening Array. Using the genomic data from UK BioBank and 23andMe studied cohorts; eight genetic variants were selected to replicate in our dataset. The allelic association was performed to identify the effective allele and risk was estimated using odds ratio and p-value as level of significance. Multifactor Dimensionality Reduction was used to estimate the cumulative effect of variants in Indians.

RESULT

Variant rs3791679 of EFEMP1 was found to be associated with varicose veins in Indians. After observing the association of the EFEMP1 with varicose veins, we further ensued to identify all genetic variants within EFEMP1 to uncover the additional variants associated with this trait. Interestingly, we identified six new variants of EFEMP1 gene that have shown association. Moreover, the cumulative effect of all associated variations was estimated and the risk was 2.7 times higher in cases than controls whereas independently their effect ranges from 0.37-1.58.

CONCLUSION

This study identifies EFEMP1 as a potential gene related to the risk of varicose veins in Indians. It also highlights that evaluating the maximum number of variants of a gene rather than focusing solely on replicating single variations offers a more comprehensive and nuanced understanding of the genetic factors contributing to a complex trait like varicose veins.

Incidence and Risk Factors for Hyponatremia in Hospitalized Children with Lower Respiratory Tract Infections

Lower respiratory tract infection (LRTI) is an important cause of hospitalization in pediatric population. Hyponatremia is frequently present in children hospitalized with pneumonia and bronchiolitis and is associated with poorer outcomes. We conducted a study to identify the risk factors for hyponatremia in hospitalized children with LRTI and to evaluate the relationship between serum sodium levels and severity of respiratory distress. A total of 147 patients between 2 months and 12 years of age, admitted with the diagnosis of LRTI at the Mahatma Gandhi Mission Hospital and Medical College, a tertiary hospital in Navi Mumbai, Maharashtra, India, between December 2017 and November 2019, were studied prospectively. Patients with any other comorbidities were excluded. The severity of respiratory distress at presentation was graded using the Clinical Respiratory score (CRS). Serum electrolytes were sent within 1 hour of hospital admission. Median age of enrolled patients was 14 months. Overall, 23 (16%) children had mild respiratory distress, 97 (66%) had moderate respiratory distress, and 26 (18%) had severe distress. The incidence of hyponatremia in children admitted with LRTI was 66% and majority of them (70%) had mild hyponatremia. The incidence, as well as severity of hyponatremia differed significantly with etiology (p < 0.05). An inverse correlation was found between serum sodium levels and CRS at presentation (r = − 0.26, p = 0.001). In multivariate analyses, parenchymal disease was an independent risk factor for development of hyponatremia (adjusted odds ratio [aOR] = 5.64 (2.52–12.59), p < 0.001). Incidence and severity of hyponatremia in children with LRTI increased with severity of respiratory distress and presence of parenchymal disease.

Carotid artery web with fetal posterior cerebral artery variant masquerading as recurrent ipsilateral cryptogenic ischaemic strokes

A 31-year-old woman was referred to vascular surgeons with the history of recurrent ischaemic strokes in two cerebral artery territories over a span of 1 year. On investigation, she was found to have a right internal carotid artery web, with thrombus and a fetal right posterior cerebral artery (PCA), which explained the ischaemic strokes in right middle cerebral and PCA territory. The rare association of these two infrequent entities makes the case a singular one in the medical literature. Successful surgical excision was done after multidisciplinary teamwork. The carotid web was excised as part of carotid artery endarterectomy and repaired with great saphenous vein patch angioplasty. The patient made a good recovery.

Early Experience with Sine Wave Technique for Superficialization of a difficult to cannulate Arterio Venous Fistula

OBJECTIVE

To highlight safety and efficacy of sine wave technique (SWT) in superficializing deep arterio venous fistula (AVF) and managing infiltrations and other complications.

METHODS

It is a single center observational study done from Jul 2017 to July 2020. All successive cases of deep AVFs, aneurysm / pseudoaneurysms of AVFs, and AVFs requiring open venoplasty were managed with SWT. Data was collected prospectively and analyzed. SWT is based on random pattern skin flaps. Using ultrasound, a line is marked on either side of centre line (AVF) at a distance of approximately 1.5-2 cm. A sine wave is drawn starting from either of the lines to the other with multiple crests and troughs. The base of flap should be double the height of the flap, that is, about 3-4 cm. Skin is incised and flaps are raised at level of AVF. Excess fat is removed. A sliver of unhealthy skin can be sacrificed if required. Flaps are sutured back to restore sine wave continuity.

RESULTS

SWT was used in a total of eleven patients. Median age was 58 years (range 10-67 years). Eight were females and three males. One was radio-cephalic and rest were brachio-cephalic AVFs. Eight AVFs were deep with median depth of 10.25mm (range 8-13mm), median body mass index of 25.5 kg/m² (range 23.9-26.5kg/m²), median vein diameter of 7 mm (range 6-8 mm), and median flow rate of 1137.5ml/min (range 650- 1380 ml/min). Out of eight, four AVFs presented with infiltration. In other three, SWT was used for exposing AVF to treat underlying pathology (one case each of aneurysm, pseudoaneurysm & stenosis). Ten cases were done under local or regional anesthesia and one under general anesthesia. There was no peri-operative mortality or loss of AVF. Transient limb oedema developed in one case. Median time to cannulate was 20 days (range 13-28 days). Median follow up was 13 months (range 6 - 31months). Cumulative patency at 18 months was 90% (95% CI 47.3%-98.53%) and 45 % (95% CI 9.9%-87.1%) at 24months and at the end of the study.

CONCLUSION

SWT is safe and effective in superficialization of deep / difficult to cannulate AVF as well a good approach to treat complications like infiltration. Post procedure cannulation time is reasonably short.

Polymorphic light eruption and IL-1 family members: any difference with allergic contact dermatitis?

Polymorphic light eruption (PLE) is described as a delayed-type hypersensitivity reaction (DTHR) toward a de novo light-induced antigen, yet to be identified. In effect, the inflammatory pathways of PLE and allergic contact dermatitis (ACD) share common patterns in terms of the mediators involved from the innate and adaptive immune system participating in the DTHR. As we have previously highlighted the role of interleukin (IL)-1 family members in ACD, we hypothesised that the same mediators could have similar functions in PLE. Our research aimed to assess the expression of certain IL-1family members in PLE patients vs. controls, and to compare it with ACD. The study population comprised 17 patients with PLE, 5 affected by ACD and 10 healthy controls in the same age range. Lesional and healthy skin samples were collected respectively from patients and donors. IL-36α, IL-36β, IL-36γ, IL-36 receptor antagonist (Ra), IL-1β, IL-33 gene and protein expressions were evaluated through RT-PCR and immunohistochemistry. Circulating proteins in the PLE patients were analysed by using western blot. The IL-36γ gene expression was significantly increased in PLE lesions compared to that in healthy controls and ACD lesions (***p < 0.001; ##p < 0.01 respectively), whereas the other analyzed ILs were more expressed in ACD. Immunohistochemical analysis revealed that IL-36α and IL-36γ protein levels were increased in PLE lesions compared to those of the healthy samples (***p < 0.001). Furthermore the IL-36γ plasma level was increased in PLE patients vs. controls (*p < 0.05). Our findings indicate that the IL-1 family pro-inflammatory members are increased in PLE with distinct differences from those in ACD, in particular with regard to IL-36γ mRNA regulation. Their role as activators of the local, and perhaps systemic, immune response, or as inhibitors of the immune tolerance machinery, needs further investigation.

Plasmodium vivax cerebral malaria

We report two cases of Plasmodium vivax malaria (both aged 12 years) complicated by seizures and symptoms of diffuse meningoencephalitis. One had predominantly meningeal signs while in the other, purely encephalitis features were present. Both cases were treated with artesunate. Rarely, cerebral malaria is a presenting complication or occurs during the course of P. vivax infection.

Adrenal and renal metastases from follicular thyroid cancer

Patients with differentiated thyroid cancer may have asymptomatic involvement of renal and/or adrenal gland, particularly if they are elderly and have associated metastases to other organs, which may remain undetected if these patients are not subjected to radioiodine treatment. Our experience also emphasises the role of routine post-radioiodine therapy whole body scan with high degree of clinical suspicion, which may reveal lesions otherwise not discernable in low dose whole body scan. All suspicious lesions should be subjected to structural imaging like ultrasound, CT or MRI for confirmation. In this setting, the role of radioiodine therapy is primarily aimed at palliation that might prolong their survival, probably reduce further spread and thus overall improve the quality of life.