Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches

PURPOSE

To evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation.

MATERIALS AND METHODS

A single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention.

RESULTS

The HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention.

CONCLUSION

Direct hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.

Intra-femoral tunnel graft lengths less than 20 mm do not predispose to early graft failure, inferior outcomes or poor function. A prospective clinico-radiological comparative study

PURPOSE

Increasing demands on skills with mounting pressures from expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions requires precise knowledge of technical details by surgeons. One such element is the minimum length of graft in femoral tunnel to allow for adequate tendon-to-bone healing and early return to activities and sports. This has, however, remained an unanswered question.

PURPOSE

To study and compare clinico-radiological outcomes of ACL reconstructions in patients with < 20 mm of intra-femoral tunnel graft length with those measuring ≥ 20 mm.

METHODS

All eligible patients undergoing arthroscopic ACL reconstruction were sequentially divided into two groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively evaluated in clinics by physical examination and functional scoring (Lysholm and modified Cincinnati scores) at 3, 6 and 12-month intervals. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using magnetic resonance imaging (MRI) at 3 and 12 months.

RESULTS

No significant differences were noted in mean Lysholm and modified Cincinnati scores between the two groups at the end of 1 year. There were also no significant differences in graft maturation over time and SNQR at 3 and 12 months in the region of interest (ROI).

CONCLUSIONS

Intra-femoral tunnel graft length of less than 20 mm does not compromise early clinical and functional outcomes of ACL reconstructions.

The management of severe aortic stenosis during the COVID-19 pandemic: an observational study comparing TAVI and SAVR

Introduction

Outcomes and characteristics of patients with severe aortic stenosis (AS) treated during the COVID-19 pandemic is unknown.

Methods

This was a single-centre observational study of patients undergoing AS treatment with transcatheter (TAVI) or surgical (SAVR) therapy during the first-wave of the UK COVID-19 pandemic compared to a control cohort undergoing treatment in 2019.

Demographics, baseline echocardiogram, CT, procedural characteristics and outcome data were collated. The primary outcome was 30-day all-cause mortality. The secondary endpoint was duration of post-procedural hospitalisation.

Results

319 patients were recruited - 122 underwent intervention during the pandemic [73 TAVI; 49 SAVR] and 197 in 2019 [127 TAVI; 70 SAVR].

In 2020, TAVI patients had a higher Euroscore II (p&lt;0.001) but there were no differences in procedural complications or mortality [p=0.16] compared to TAVI 2019 cases. Duration from TAVI to discharge was shorter in 2020 (p&lt;0.001).

SAVR 2020 patients had similar baseline profile [p=0.48], surgical characteristics, mortality (p=0.68) and duration from SAVR to discharge compared to those in 2019.

During the pandemic, TAVI patients were older (p&lt;0.001) and had a higher Euroscore II (p&lt;0.001) than SAVR counterparts. TAVI patients had reduced 30-day mortality [0 (0%) vs 3 (6%); p=0.06] and were discharged more rapidly post-intervention than SAVR patients [median 1 [1] vs 7 [4] days; p&lt;0.001) translating into shorter hospitalization (p&lt;0.001).

Conclusions

TAVI and SAVR can be safely delivered with predictable resource utilisation during a pandemic. Despite the TAVI cohort incorporating higher risk, older patients, outcomes were at least as good as SAVR with a shorter length of post-procedural hospitalisation.

Funding Acknowledgement

Type of funding sources: None. Procedural Complications TAVI/SAVRDuration to discharge post TAVI/SAVR

A perspective on the role of uncertainty in sustainability science and engineering

The Trans-Atlantic Research and Development Interchange on Sustainability Workshop (TARDIS) is a meeting on scientific topics related to sustainability. The 2019 workshop theme was "On the Role of Uncertainty in Managing the Earth for Global Sustainability." This paper presents the perspectives on this topic derived from talks and discussions at the 2019 TARDIS workshop. There are four kinds of uncertainties encountered in sustainability ranging from clear enough futures to true surprises. The current state-of-the-art in assessing and mitigating these uncertainties is discussed.

PRP versus steroids in a deadlock for efficacy: long-term stability versus short-term intensity-results from a randomised trial

PURPOSE

A popular choice for lateral epicondylitis (LE), corticosteroid injections have been associated with prominent side effects, which has led to the conception of modalities like platelet-rich plasma (PRP). This randomised trial aimed to evaluate and compare the 6-week, 3-month and 1-year outcomes with PRP and corticosteroid injections in LE. We hypothesised that PRP would prove more effective in relieving pain and improving function.

METHODS

At the sports medicine unit of our tertiary care teaching centre, 80 patients with LE were randomised into either receiving PRP (group A) or corticosteroids (group B) injections. Pre-injection visual analogue scale (VAS), disabilities of the arm, shoulder and hand (DASH) score, Mayo elbow performance score (MEPS) and grip strength score (GSS) were recorded. Common extensor origins were identified and infiltrated with 3 ml of either PRP or corticosteroid (triamcinolone in 2% xylocaine) using a peppering technique. Follow-up scores and extent of pain relief were recorded and compared.

RESULTS

At 6 weeks, there were greater improvements in group B versus A in mean VAS (13.8 vs. 44.5; p < 0.001), DASH (64.2 vs. 53.3; p < 0.001), MEPS (88.0 vs. 74.5; p = 0.004) and GSS (89.3 vs. 73.4; p = 0.039). These scores showed a reversed pattern at 3 months when group A outcomes superseded group B (VAS p = 0.002; DASH p < 0.001; MEPS p = 0.002; GSS p = 0.045). At 1-year follow-up, group A continued to enjoy better pain relief and function (VAS p = 0.024; DASH p < 0.001; MEPS p = 0.009; GSS p = 0.028).

CONCLUSIONS

Albeit corticosteroid injections show good short-term results at 6 weeks, patients receiving PRP injections fare better at 3 and 12 months.

Pre-discharge postoperative radiographs after primary total knee replacement : tradition or science?

Consistent evidence exists on the inutility of immediate postoperative radiographs after a total knee replacement (TKR). We hypothesized that eliminating the pre-discharge film would not have any effect on the postoperative patient outcomes. Retrospective analysis of prospectively collected data was performed on 220 knees. Patients undergoing a simple primary TKR operated by 2 surgeons (Surgeon A and B) from January 2013 to July 2015 were divided into 2 groups (Groups 1 and 2 having 112 and 108 knees respectively). While Surgeon A routinely asked for the second postoperative day pre-discharge radiograph, Surgeon B directly performed weight bearing radiographs 6 weeks postoperatively. Greater knee pain was seen in Group 1 (p = 0.01). No changes in rehabilitation protocols based on pre-discharge radiographs, complications, medico-legal issues or revision surgery could be identified in any patient. The quality of the pre-discharge radiographs was adequate in 65 of the 112 knees (58%). A cost reduction of approximately $220 per patient was observed with the exclusion of the pre-discharge film. Eliminating routine inpatient pre-discharge radio-graphs after simple primary TKR does not alter the rehabilitation protocol, identify any of the standard complication or have any medico-legal implications. On the contrary, these films seem to increase postoperative pain and costs.

Spatially resolved ultrafast magnetic dynamics initiated at a complex oxide heterointerface

Static strain in complex oxide heterostructures has been extensively used to engineer electronic and magnetic properties at equilibrium. In the same spirit, deformations of the crystal lattice with light may be used to achieve functional control across heterointerfaces dynamically. Here, by exciting large-amplitude infrared-active vibrations in a LaAlO3 substrate we induce magnetic order melting in a NdNiO3 film across a heterointerface. Femtosecond resonant soft X-ray diffraction is used to determine the spatiotemporal evolution of the magnetic disordering. We observe a magnetic melt front that propagates from the substrate interface into the film, at a speed that suggests electronically driven motion. Light control and ultrafast phase front propagation at heterointerfaces may lead to new opportunities in optomagnetism, for example by driving domain wall motion to transport information across suitably designed devices.

Does the response to aspirin and clopidogrel vary over 6 months in patients with ischemic heart disease?

BACKGROUND

Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, mostly clopidogrel, is the default therapy in both acute coronary syndrome (ACS) and after intracoronary stents. It is well established that responses to antiplatelet therapy (APT), particularly clopidogrel, are subject to considerable interindividual variability.

OBJECTIVES

We investigated whether responses to APT in individuals vary significantly over time.

METHODS

Simultaneous assay with VerifyNow(™) and short thrombelastography (s-TEG) was performed before and at four time points over 6 months after hospital discharge in 40 patients receiving DAPT. Serum thromboxane B2 levels were also measured.

RESULTS

While aspirin response units (ARU) by VerifyNow(™) and serum thromboxane B2 levels remained stable over time, arachidonic acid (AA)-mediated platelet aggregation with s-TEG (i.e. area under the curve at 15 min in AA channel, AUC15AA ) increased at 1 week compared with predischarge (P < 0.008). In addition, platelet reactivity units (PRU) by VerifyNow(™) (P = 0.046) and adenosine diphosphate (ADP)-mediated platelet aggregation with s-TEG (i.e. AUC15ADP ) also increased at 1 week compared with predischarge (P = 0.026). There were no significant changes in either platelet reactivity or rates of high on-treatment platelet reactivity while receiving clopidogrel beyond 1 week.

CONCLUSIONS

This study demonstrates important variability in responses to APT within individuals between predischarge and 1 week but not thereafter. The use of a single early (predischarge) platelet function assay as an indicator of future response may therefore be flawed. The design of future strategies to assess individual responses for tailored therapy needs to take this into account.

Cartilage restoration of the hip using fresh osteochondral allograft

Cartilage defects of the hip cause significant pain and may lead to arthritic changes that necessitate hip replacement. We propose the use of fresh osteochondral allografts as an option for the treatment of such defects in young patients. Here we present the results of fresh osteochondral allografts for cartilage defects in 17 patients in a prospective study. The underlying diagnoses for the cartilage defects were osteochondritis dissecans in eight and avascular necrosis in six. Two had Legg-Calve-Perthes and one a femoral head fracture. Pre-operatively, an MRI was used to determine the size of the cartilage defect and the femoral head diameter. All patients underwent surgical hip dislocation with a trochanteric slide osteotomy for placement of the allograft. The mean age at surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months (3 to 74). The mean Harris hip score was significantly better after surgery (p < 0.01) and 13 patients had fair to good outcomes. One patient required a repeat allograft, one patient underwent hip replacement and two patients are awaiting hip replacement. Fresh osteochondral allograft is a reasonable treatment option for hip cartilage defects in young patients.

Cite this article: Bone Joint J 2014;96-B(11 Supple A):11–16.

Melting of charge stripes in vibrationally driven La(1.875)Ba(0.125)CuO4: assessing the respective roles of electronic and lattice order in frustrated superconductors

We report femtosecond resonant soft x-ray diffraction measurements of the dynamics of the charge order and of the crystal lattice in nonsuperconducting, stripe-ordered La1.875Ba0.125CuO4. Excitation of the in-plane Cu-O stretching phonon with a midinfrared pulse has been previously shown to induce a transient superconducting state in the closely related compound La1.675Eu0.2Sr0.125CuO4. In La1.875Ba0.125CuO4, we find that the charge stripe order melts promptly on a subpicosecond time scale. Surprisingly, the low temperature tetragonal (LTT) distortion is only weakly reduced, reacting on significantly longer time scales that do not correlate with light-induced superconductivity. This experiment suggests that charge modulations alone, and not the LTT distortion, prevent superconductivity in equilibrium.

Optical excitation of Josephson plasma solitons in a cuprate superconductor

Josephson plasma waves are linear electromagnetic modes that propagate along the planes of cuprate superconductors, sustained by interlayer tunnelling supercurrents. For strong electromagnetic fields, as the supercurrents approach the critical value, the electrodynamics become highly nonlinear. Josephson plasma solitons (JPSs) are breather excitations predicted in this regime, bound vortex-antivortex pairs that propagate coherently without dispersion. We experimentally demonstrate the excitation of a JPS in La1.84Sr0.16CuO4, using intense narrowband radiation from an infrared free-electron laser tuned to the 2-THz Josephson plasma resonance. The JPS becomes observable as it causes a transparency window in the opaque spectral region immediately below the plasma resonance. Optical control of magnetic-flux-carrying solitons may lead to new applications in terahertz-frequency plasmonics, in information storage and transport and in the manipulation of high-Tc superconductivity.

Utility of thyroid collars in cephalometric radiography

OBJECTIVE

A study was carried out to investigate the rationale that use of a thyroid collar (TC) in cephalometric radiography hampers the diagnostic and descriptive quality of lateral cephalogram.

METHODS

A randomized observer blinded study was designed. The study consisted of two groups. The first group data were retrieved from the oral radiology archival system having lateral cephalogram without a TC. The second group was selected from the oral radiology department of patients where lateral cephalogram was taken using a TC. Lateral cephalogram was taken on direct digital system, the Kodak 9000 unit (Eastman Kodak, Rochester, NY). 2 observers blinded about the aim of the study were appointed to identify 15 sets of landmarks on the lateral cephalogram. Interobserver variance was also analysed for the study.

RESULTS

50 lateral cephalograms in each group were studied. Out of 15 sets of landmarks, 12 were identified consistent with the TC group. Three landmarks, namely the hyoid bone, second cervical vertebra and third cervical vertebra could not be identified on the TC group. There was no significant difference in the interobserver markings on lateral cephalogram.

CONCLUSIONS

TCs do mask a few landmarks on the lateral cephalogram. These landmarks are mainly used for analysis of skeletal maturity index (SMI). Lead TCs are probably the most convenient and easily available means to protect the thyroid from unwanted radiation while taking lateral cephalogram. It is therefore encouraged to use a TC during routine cephalometric radiography where SMI information is not needed.

Cleft lip: The historical perspective

The earliest documented history of cleft lip is based on a combination of religion, superstition, invention and charlatanism. While Greeks ignored their existence, Spartans and Romans would kill these children as they were considered to harbour evil spirits. When saner senses prevailed Fabricius ab Aquapendente (1537–1619) was the first to suggest the embryological basis of these clefts. The knowledge of cleft lip and the surgical correction received a big boost during the period between the Renaissance and the 19th century with the publication of Pierre Franco's Petit Traité and Traité des Hernies in which he described the condition as “lievré fendu de nativité” (cleft lip present from birth). The first documented Cleft lip surgery is from China in 390 BC in an 18 year old would be soldier, Wey Young-Chi. Albucasis of Arabia and his fellow surgeons used the cautery instead of the scalpel and Yperman in 1854 recommended scarifying the margins with a scalpel before suturing them with a triangular needle dipped in wax. The repair was reinforced by passing a long needle through the two sides of the lip and fixing the shaft of the needle with a figure-of-eight thread over the lip. Germanicus Mirault can be credited to be the originator of the triangular flap which was later modified by C.W. Tennison in 1952 and Peter Randall in 1959. In the late 50s, Ralph Millard gave us his legendary ‘cut as you go’ technique. The protruding premaxilla of a bilateral cleft lip too has seen many changes throughout the ages – from being discarded totally to being pushed back by wedge resection of vomer to finally being left to the orthodontists.

Oral tuberculosis: unusual radiographic findings

Oral tuberculosis and its radiographic findings are not commonly encountered in an oral and maxillofacial radiology practice. Literature has occasional mention of the radiographic findings of oral tuberculosis, which are still ambiguous. When affected, it is manifested majorly in the oral mucosa and rarely in the jaw bones. Here, we report certain unusual radiographic findings of oral tuberculosis which have been rarely mentioned in the literature. Four illustrative cases describe bony resorption, condylar resorption, resorption of the inferior border of the mandible and rarefaction of the alveolar bone as radiographic findings of oral tuberculosis. Follow up of the first case demonstrated regeneration of the condylar head after anti-Kochs therapy was completed, a hitherto unreported phenomenon. The importance of including tuberculosis in the differential diagnosis of some of the unusual radiographic manifestations is emphasized.

Atrial fibrillation: epidemiology, prognosis and therapy

Atrial fibrillation is the most common cardiac tachyarrhythmia encountered in clinical practice affecting 1% of the population. It is characterized by uncoordinated atrial activation that can lead to embolic complications and reduction in cardiac output resulting in significant morbidity, mortality and a reduction in quality of life. The three major goals in the management of atrial fibrillation are rate control, prevention of thromboembolism and correction of rhythm disturbance. This article will review up-to-date thinking about strategies for achieving each of these fundamental goals of AF care, with an emphasis on new drugs such as dabigatran and dronedarone and emerging non-pharmacologic therapies such as catheter ablation and left atrial appendage exclusion. After many years with relatively few new treatments, the past few years have seen a number of exciting developments which will hopefully improve clinician's ability to improve the outcomes of patients with this chronic and troublesome condition.

Photoinduced melting of antiferromagnetic order in La(0.5)Sr(1.5)MnO4 measured using ultrafast resonant soft x-ray diffraction

We used ultrafast resonant soft x-ray diffraction to probe the picosecond dynamics of spin and orbital order in La(0.5)Sr(1.5)MnO(4) after photoexcitation with a femtosecond pulse of 1.5 eV radiation. Complete melting of antiferromagnetic spin order is evidenced by the disappearance of a (1/4,1/4,1/2) diffraction peak. On the other hand, the (1/4,1/4,0) diffraction peak, reflecting orbital order, is only partially reduced. We interpret the results as evidence of destabilization in the short-range exchange pattern with no significant relaxation of the long-range Jahn-Teller distortions. Cluster calculations are used to analyze different possible magnetically ordered states in the long-lived metastable phase. Nonthermal coupling between light and magnetism emerges as a primary aspect of photoinduced phase transitions in manganites.

Early victims of X-rays: a tribute and current perception

X-rays were discovered in 1895 and since then much has been written about Wilhelm Roentgen and the events surrounding the discovery. However, there have been only scattered references in the literature about the early workers who dedicated their life, and death, to X-rays. Radiology has come of age since then. Large exposure times have been reduced to milliseconds and there has been a change from analogue to digital. The advent of new and rapidly developing modalities and the ubiquitous presence of cone beam CT (CBCT) highlight the need to remember the early victims of X-rays, especially with the lack of universal guidelines for taking a CBCT scan. The aim of this article is to alert the oral radiologist to exposing patients irrespective of need, and to pay respect to the victims on the 116(th) anniversary of the discovery of X-rays.

The role of maxillofacial radiologists in gunshot injuries: a hypothesized missile trajectory in two case reports

Gunshot injuries are an emerging form of trauma that oral radiologists increasingly have to deal with. There are two main types of gunshot injuries: high-velocity and low-velocity bullet injuries. The outcome of high-velocity gunshot injury is usually fatal; however, a non-fatal low-velocity injury to the maxillofacial region is more likely to be encountered by the oral and maxillofacial radiologist. It is therefore important to up-to-date knowledge of ballistic science and its implications in the field of maxillofacial radiology. The ability of oral and maxillofacial radiologists to predict the missile trajectory will aid the assessment and localization of the damage caused by the bullet and its splinters. Predicting the missile trajectory may also be of help to law enforcement agencies and forensic scientists in determining the type of firearm used and direction of fire. This article, which examines two cases, attempts to highlight to the oral radiologist this emerging form of trauma and its implications.

Association of severity of COPD with IgE and interleukin-1 beta

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a pulmonary inflammatory disease characterised by airflow limitation. The role of various inflammatory mediators such as interleukin-1beta (IL-beta) and Immunoglobulin E (IgE) have been implicated in COPD. In present study we aimed to establish if there is an association between the serum levels of IL-1beta and IgE and the severity of airway obstruction.

MATERIALS AND METHODS

The study group comprised of 30 non atopic smokers, suffering from COPD and 30 non smoker, healthy controls. Serum levels of IgE and IL-1beta were assayed by ELISA in all subjects along with their pulmonary function tests.

RESULTS

Serum IgE and IL-1beta levels were significantly raised in COPD patients as compared to healthy controls. IL-1beta was negatively correlated with FEV1 (r = -0.624, p = 0.003) and IgE showed a negative correlation with FVC (r = -0.477, p = 0.034).

CONCLUSION

Our study suggests that in COPD IL-1beta and IgE serum levels correlate with clinical aspects of disease severity. We suggest that the production of IgE and IL-1beta in the airways of patients with COPD may be related to smoking which affects airway obstruction.

Comparison of conventional transarterial chemoembolization (TACE) and chemoembolization with doxorubicin drug eluting beads (DEB) for unresectable hepatocelluar carcinoma (HCC)

BACKGROUND AND OBJECTIVES

Chemoembolization with doxorubicin drug eluting beads (DEB) is a novel locoregional treatment modality for unresectable hepatocellular carcinoma (HCC). Initial animal studies and clinical trials suggest that treatment with DEB may provide safer and more effective short-term outcomes than conventional chemoembolization. Current study explores long-term survival benefits.

METHODS

Consecutive patients who received transcatheter therapy with DEB or conventional chemoembolization as sole therapy between 1998 and 2008 were studied. Statistical analysis was performed using Kaplan-Meier estimator with log-rank testing, chi-squared, and independent t-tests.

RESULTS

Seventy-one patients were included in this study, 45 (63.4%) received therapy with DEB (group A) and 26 (36.6%) underwent conventional chemoembolization (group B). Median survival from diagnosis of HCC in groups A and B were 610 (351-868) and 284 days (4-563; P = 0.03), respectively. In Okuda stage I, survival in groups A and B were 501 (421-528) and 354 days (148-560, P = 0.02). In Child-Pugh classes A and B, survival in groups A and B were 641 (471-810) and 323 days (161-485, P = 0.002). Median survival in patients with Cancer of Liver Italian Program (CLIP) score <or=3 in groups A and B were 469 (358-581) and 373 days (195-551, P = 0.03). NCI CTCAEv3 Grade 5 clinical toxicity was similar.

CONCLUSIONS

In our study, transcatheter therapy with DEB offers a survival advantage over conventional chemoembolization for patients with unresectable HCC.

Prognostic factors for survival in patients with unresectable hepatocellular carcinoma undergoing chemoembolization with doxorubicin drug-eluting beads: a preliminary study

BACKGROUND

Transarterial chemoembolization (TACE) with drug-eluting beads (DEB) is a new treatment modality. Little is known about prognostic factors affecting survival after DEB TACE for patients with hepatocellular carcinoma (HCC).

METHODS

Patients who underwent TACE with doxorubicin DEB for unresectable HCC during 2006-2008 were studied. Survival was calculated from the day of first transcatheter therapy. Survival analysis was performed using Kaplan-Meier estimations. Survival curves were compared using the log-rank test.

RESULTS

Fifty patients underwent chemoembolization with doxorubicin DEB. They included 39 women and 11 men, with a median age of 57.5 years (range 28-91 years). Eighteen patients died during the study period and 32 remained alive. Overall survival rates at 6 months, 1 year and 2 years from the first administration of doxorubicin DEB TACE were 71%, 65% and 51%, respectively. Prognostic factors found to be significant on univariate analysis were Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3.0 g/dl, Model for End-stage Liver Disease (MELD) score, serum alphafetoprotein (AFP), Cancer of the Liver Italian Programme (CLIP) score, tumour satisfying Milan criteria, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and Barcelona Clinic Liver Cancer (BCLC) staging.

CONCLUSIONS

Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3 g/dl, MELD score, serum AFP, CLIP score, Milan criteria, ECOG PS and BCLC staging were found to be prognostic markers of survival after treatment with doxorubicin DEB TACE in patients with unresectable HCC.

Cleft lip: The historical perspective

The earliest documented history of cleft lip is based on a combination of religion, superstition, invention and charlatanism. While Greeks ignored their existence, Spartans and Romans would kill these children as they were considered to harbour evil spirits. When saner senses prevailed Fabricius ab Aquapendente (1537–1619) was the first to suggest the embryological basis of these clefts. The knowledge of cleft lip and the surgical correction received a big boost during the period between the Renaissance and the 19th century with the publication of Pierre Franco's Petit Traité and Traité des Hernies in which he described the condition as “lièvre fendu de nativitè” (cleft lip present from birth). The first documented Cleft lip surgery is from China in 390 BC in an 18 year old would be soldier, Wey Young-Chi. Albucasis of Arabia and his fellow surgeons used the cautery instead of the scalpel and Yperman in 1854 recommended scarifying the margins with a scalpel before suturing them with a triangular needle dipped in wax. The repair was reinforced by passing a long needle through the two sides of the lip and fixing the shaft of the needle with a figure-of-eight thread over the lip. Germanicus Mirault can be credited to be the originator of the triangular flap which was later modified by C.W. Tennison in 1952 and Peter Randall in 1959. In the late 50s, Ralph Millard gave us his legendary ‘cut as you go’ technique. The protruding premaxilla of a bilateral cleft lip too has seen many changes throughout the ages OE from being discarded totally to being pushed back by wedge resection of vomer to finally being left to the orthodontists.

Towards precise prediction of transport properties from synthetic computer tomography of reconstructed porous media

Transport properties of a multiscale carbonate rock are predicted from pore scale models, reconstructed using a continuum geometrical modeling technique. The method combines crystallite information from two-dimensional high-resolution images with sedimentary correlations from a three-dimensional low-resolution microcomputed tomography ( micro-CT) image to produce a rock sample with calibrated porosity, structural correlation, and transport properties at arbitrary resolutions. Synthetic micro-CT images of the reconstructed model match well with experimental micro-CT images at different resolutions, making it possible to predict physical transport parameters at higher resolutions.

Splenic Syndrome due to Sickle Cell Trait amongst Indian Soldiers Serving in Kashmir

BACKGROUND

Heterozygous transmission of gene for Haemoglobin S leads to sickle cell trait. Mostly the trait remains silent with no additional morbidity or mortality. When these persons migrate to higher altitudes, in times of high oxygen demand, some of them develop splenic infarction. This is a rare phenomenon and only 47 such cases had been reported till 2005.

METHODS

This study was conducted at an Indian military hospital serving the troops deployed in Kashmir valley at altitudes ranging from 5500 ft to 13000 ft. When two consecutive splenectomies for splenic abscesses, turned out to be sickling induced infarction histopathologically, we reviewed splenectomy specimens received in last six years for evidence of sickling.

RESULT

Out of 33 splenectomies performed during the period of study, 22 were due to trauma (gun shot injury 11; splinter injury one and blunt injury 10). Of the rest eleven, who presented without any history of trauma, seven had evidence of vascular occlusion with aggregates of sickled red blood cells. In none, Gram stain or Periodic Acid Schiff stain revealed any bacterial or fungal colonies. One patient of splenic syndrome was found to have unrecognised sickle cell trait and he was managed conservatively.

CONCLUSION

Sickle cell trait should be excluded before considering splenectomy in ethnically vulnerable patients presenting with splenic syndrome. An uncomplicated splenic infarction can be managed conservatively.

Lymphoma presenting as an ejection systolic murmur

We report the case of a 22-year-old gentleman with non-Hodgkin's lymphoma who presented with a 3-week history of non-specific symptoms and an ejection systolic murmur. Urgent transthoracic echocardiography demonstrated a large anterior mediastinal mass compressing the right ventricular outflow tract that was confirmed on subsequent computerised tomography.

Increase in weight induced by muraglitazar, a dual PPARalpha/gamma agonist, in db/db mice: adipogenesis/or oedema?

BACKGROUND AND PURPOSE

Muraglitazar, a dual PPARalpha/gamma agonist, caused a robust increase in body weight in db/db mice. The purpose of the study was to see if this increase in weight was due to oedema and/or adipogenesis.

EXPERIMENTAL APPROACH

The affinity of muraglitazar at PPARalpha/gamma receptors was characterized using transactivation assays. Pre-adipocyte differentiation, expression of genes for adipogenesis (aP2), fatty acid oxidation (ACO) and sodium reabsorption (ENaCgamma and Na+, K+-ATPase); haemodilution parameters and serum electrolytes were measured to delineate the role of muraglitazar in causing weight gain vis a vis rosiglitazone.

KEY RESULTS

Treatment with muraglitazar (10 mg kg(-1)) for 14 days significantly reduced plasma glucose and triglycerides. Reduction in plasma glucose was significantly greater than after similar treatment with rosiglitazone (10 mg kg(-1)). A marked increase in weight was also observed with muraglitazar that was significantly greater than with rosiglitazone. Muraglitazar increased aP2 mRNA and caused adipocyte differentiation in 3T3-L1 cells similar to rosiglitazone. It also caused a marked increase in ACO mRNA in the liver of the treated mice. Expression of mRNA for ENaCgamma and Na+, K+-ATPase in kidneys was up-regulated after either treatment. Increased serum electrolytes and decreased RBC count, haemoglobin and haematocrit were observed with both muraglitazar and rosiglitazone.

CONCLUSIONS AND IMPLICATIONS

Although muraglitazar has a better glucose lowering profile, it also has a greater potential for weight gain than rosiglitazone. In conclusion, muraglitazar causes both robust adipogenesis and oedema in a 14-day treatment of db/db mice as observed in humans.

Comparative study of primary and recurrent ovarian serous carcinomas: comparative genomic hybridization analysis with a potential application for prognosis

OBJECTIVES

The purpose of this study is to comparatively characterize genomic imbalances in primary and recurrent ovarian serous carcinomas and to identify genomic alterations that may be used as a marker for prognosis.

METHODS

Twenty ovarian serous carcinomas were studied by comparative genomic hybridization (CGH).

RESULTS

Genomic alterations were found in all of the tumors. The most common regions involving gain of DNA copy numbers are 1q41q44, 8q22q24, 19p12q13.1, 20q12q13, 3q26q29, 12p12p13, 2p22p25, 7p14p21, 5p15.2p15.3, and 17q22q25. The most common regions with loss of DNA copy numbers are Xp11.2q13, 4q31q35, Xp21p22.3, 18q22q23, 13q22q31, 9p22p24, and 16q22q24. High-level gains were detected at chromosomal regions of 1q41q44, 2p22p25, 3q26q29, and 19p12q13.1. Comparative analysis of primary and recurrent tumors showed that gains of 2p22p25, 19p12q13.1, and 20q12q13 and loss of 5q14q22 were more common in the recurrent high-grade tumors. About 85% of the tumors showed increases in DNA copy numbers in the regions (2p and 8q) harboring the myc family gene. Patients with tumor containing fewer than seven chromosomal aberrations showed longer survival time.

CONCLUSION

The myc oncogene family may play a role in the pathogenesis of ovarian serous carcinomas. Our study suggests that tumors with gains of 2p22p25, 19p12q13.1, and 20q12q13 and loss of 5q14q22 may be at high risk for recurrence. Furthermore, the patients' survival time inversely correlates with the numbers of chromosomal alterations found in their tumors. CGH analysis may have a clinical application in predicting prognosis and risk of recurrence in patients with ovarian serous carcinomas.

Genomic alterations in uterine leiomyosarcomas: potential markers for clinical diagnosis and prognosis

Genomic alterations were analyzed in 21 uterine leiomyosarcomas (ULMSs) by comparative genomic hybridization. DNA copy number changes were detected in all 21 tumors. The most frequent losses were 13q (16/21 = 76%), 10q (13/21 = 62%), 16q (8/21 = 38%), 12p (7/21 = 33%), and 2p (9/21 = 43%). The most common gains were 17p (8/21 = 38%), Xp (7/21 = 33%), and 1q (7/21 = 33%). High-copy-number gains (ratio > 1.5) were identified in Xp, 1q, and 17p. Loss of 13q was identified in both low-grade and high-grade tumors. Inactivation of a tumor suppressor gene in 13q may be an early event in the development of leiomyosarcomas. Loss of 10q, 2p, and 12p and gains of 1q as well as 17p were frequently found in high-grade tumors and recurrent tumors. Inactivation of tumor suppressor genes and activation of oncogenes in these regions may be associated with a more aggressive behavior of ULMS. Patients with only loss of 13q and without the other alterations listed above had longer survival times. Gains of Xp, 17p, and 1q and losses of 13q, 10q, 16q, 12p, and 2p have been reported in extra-uterine leiomyosarcomas. Our findings indicate that the pathogenesis of uterine leiomyosarcomas and extra-uterine leiomyosarcomas follows the same genetic pathways.

Clinicomicrobiologic evaluation of active tubotympanic type chronic suppurative otitis media

OBJECTIVES

This prospective study was conducted to determine the spectrum of micro-organisms encountered in patients with active-stage chronic suppurative otitis media (CSOM) (tubotympanic type) and to see whether prescribing an antibiotic after culture sensitivity was more beneficial as compared to initial treatment without cultures.

DESIGN

Prospective randomized study of 110 patients of active CSOM (tubotympanic type) divided into two groups of 55 cases each.

SETTING

Departments of Ear, Nose and Throat and Microbiology of a tertiary care hospital.

METHODS

The patients in group A were prescribed an antibiotic according to the culture and sensitivity, whereas in group B, culture was not done at the first visit, and a broad-spectrum antimicrobial, namely, co-trimoxazole, was prescribed blindly for a maximum period of 2 weeks. The cases that still had ear discharge were then subjected to culture and sensitivity and the antibiotic was prescribed accordingly.

MAIN OUTCOME MEASURES

All patients in group A were subjected to bacterial culture and sensitivity and fungal culture. Only failed cases in group B were subjected to the same.

RESULTS

In group A, 47 patients (85.50%) had positive bacterial culture and 20 patients had positive fungal culture. Pseudomonas aeruginosa was the most common bacterial isolate. All of these 47 patients had a dry ear with a maximum 2 weeks of antibiotic therapy. Among the remaining 8 patients who had negative bacterial culture, 5 patients (9.0%) showed fungal isolates on culture and responded to topical antifungal treatment. The remaining 3 failed cases (5.5%) responded to daily dry mopping alone. In group B, 41 patients (74.54%) attained a dry ear. Bacterial culture and sensitivity were done in the remaining 14 (25.46%) failed cases. The culture was positive in 11 patients (20.0%) and sterile in 3 patients (5.5%). In the latter group, only 1 patient had fungus on culture and the remaining 2 patients responded to daily dry mopping alone, which was done at a maximum for a week only. The most common fungal pathogen isolated was Aspergillus flavus.

CONCLUSIONS

Pseudomonas aeruginosa was the most common bacteria and Aspergillus flavus the most common fungus isolated in this study. In group A patients, the failed cases were less as compared to the control group B, but the p value was .2. Hence, there is no definite role of culture and sensitivity in the initial management plan of all cases of CSOM. Ideally, every such case should be prescribed a broad-spectrum antibiotic and only in failed cases should culture and sensitivity be done.

Random amplified polymorphic DNA analysis of Indian scented basmati rice (Oryza sativa L.) germplasm for identification of variability and duplicate accessions, if any

Genetic variation among the seventeen basmati rice accessions collected from the farmers' fields located at different places in India was analyzed using ten arbitrary tenmer oligonucleotide primers by the random amplified polymorphic DNA (RAPD) method. The number of polymorphic/monomorphic bands among the pairwise combinations of the accessions and the total number of bands were determined to categorize all the accessions in different groups of similarity and dissimilarity at the genetic level. The procedure described also allows the identification and discrimination of the individual genotypes of basmati rice including the identification of the duplicates in genetic resource collections.