Assessing the Prevalence Rate of Gangrene Among Patients With Peripheral Vascular Disease in a Tertiary Care Hospital in Central India

Background Peripheral vascular disease (PVD) includes peripheral arterial disease (PAD) and venous disease. PAD is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion. PAD typically affects the abdominal aorta, iliac arteries, lower limbs, and occasionally the upper extremities. Assessing the prevalence of gangrene among PVD patients is crucial for understanding the burden of this condition and informing clinical management strategies. This study aimed to estimate the prevalence rate of gangrene among patients diagnosed with peripheral vascular disease. Methods This case-control study was conducted at the General Surgery department of Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Wardha, India. Patients diagnosed with PVD who presented with gangrene of the lower limb were included. Detailed demographic data were collected, and clinical examinations and diagnostic tests were performed to assess the severity and extent of gangrene. Statistical analysis was conducted to estimate the prevalence of gangrene among PVD patients. Results Among the 100 participants, the age distribution ranged from 21 to over 70 years, with a mean age of 52.89. Gender distribution showed that 30% of the participants were female and 70% were male. The prevalence of gangrene among PVD patients was found to be 35%, with 65% patients not presenting with gangrene. Conclusion The findings of this study highlight the significant prevalence of gangrene among patients diagnosed with peripheral vascular disease. The implications of these findings for clinical practice and management strategies are discussed further, along with potential avenues for further research. The study provides valuable insights into the burden of gangrene among PVD patients. Early detection and appropriate management of PVD are crucial for preventing the development of gangrene and improving patient outcomes.

A Case Report of a Metastatic Papillary Carcinoma of the Thyroid

Neck lumps can be a symptom of thyroid and parathyroid gland metabolic diseases, and papillary thyroid carcinoma is reported in some cases. It is commonly observed in middle-aged people with a female predominance. Papillary carcinoma of the thyroid is the most common type of thyroid cancer, originating from the thyroid gland cells. It is slow-growing and less aggressive, but it has been reported to have the ability to affect nearby lymph nodes and other organs. It is associated with the RET protooncogene, NTRK1, and MET genes. Early detection is crucial, especially for middle-aged patients. Treatment typically involves thyroidectomy and radioactive iodine therapy, with the need for hormone replacement therapy. Fine-needle aspiration cytology (FNAC) is an efficient and cost-effective tool for diagnosing neck swellings, leading to a conclusive diagnosis of the mass. We present a case of a 60-year-old Indian female with swelling over the neck for the past six years, which was recently accompanied by dyspnea, hand tremors, and palpitations. The ignored neck mass was found to be a hyper-echoic mass with macro calcifications and cystic degeneration on ultrasonography, confirmed as papillary thyroid carcinoma by FNAC, followed by a complete thyroidectomy and uneventful follow-up.

Sarcomatoid Carcinoma of the Breast: An Unusual Clinical Presentation

Breast sarcomatoid carcinoma, which are malignant tumors that form from the mesenchymal tissue of the mammary gland, are extremely uncommon and come in two varieties: primary and secondary (development associated to therapy). Breast sarcomas are malignancies that are aggressive and have a bad prognosis. Multidisciplinary surgery, chemotherapy, and radiotherapy are among the treatment possibilities. This case report reports a case of 35-year-old female presented to our hospital with a palpable tumor in her right breast and pungent discharge from her nipples. These signs persisted for over five years. A sarcomatoid breast cancer was discovered by postoperative histology.

Toxic Megacolon: A Sequelae of Clostridioides difficile Infection in a Case of Necrotizing Fasciitis

Necrotizing fasciitis is an illness that ascends quickly and affects the fascia, subcutaneous tissues, and deeper skin layers. To combat this infection, strong antibiotics are used along with prompt debridement. Frequent usage of such drugs is connected to antibiotic-associated diarrhea and colonic illnesses like colitis. High-spectrum antibiotic usage over an extended period of time can alter the gut microbiota, which promotes the growth of commensal bacteria including Staphylococcus aureus and Clostridioides difficile (previously known as Clostridium difficile) resulting in complications such as toxic megacolon. C. difficile infection can result in extreme inflammation and colon dilatation leading to toxic megacolon. In order to effectively treat necrotizing fasciitis, a timely diagnosis and vigorous management are essential; failing of which may have fatal consequences such as sepsis and even mortality. We present a case of a 56-year-old male, suffering from necrotizing fasciitis of the left lower limb which further complicated to toxic megacolon and caused mortality of the patient. Timely presentation and early diagnosis can be helpful in better prognosis, which in the context of this case was delayed; had the patient presented to the hospital earlier, there were chances of preventing mortality.

A Miraculous Save: Gangrenous Bowel and Meckle's Diverticulum With Acute Superior Mesenteric Artery Thrombosis

The superior mesenteric artery (SMA) is vital for parts of the small intestine and ascending colon. Thrombosis of this major artery is a severe and potentially fatal condition involving the occlusion of the arterial vascular supply, causing ischemia predisposing to gangrene. Meckel's diverticulum is a congenital outpouching in the lower part of the small intestine. The condition of gangrenous meckels diverticulum is, therefore, even more limited. This study presents a unique case of a 45-year-old male with coexisting features of SMA thrombus with acute small bowel intestinal obstruction. During the study, the patient was found to have sickle cell anemia with an AS pattern, which may have predisposed the formation of a thrombus. The patient underwent sequential management of active thrombus by thrombolysis first, followed by resection anastomosis for gangrenous bowel. With precise monitoring and therapeutic care, the patient made a remarkable recovery. The condition possesses a high mortality rate. Prompt recognition and timely intervention in this case are of utmost significance.

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

Gangrene is a grave complication of peripheral vascular disease (PVD), characterised by tissue necrosis due to inadequate blood supply. This review article comprehensively explores gangrene in PVD, encompassing its prevalence, aetiology, clinical presentation, diagnostic modalities, management strategies, prognosis, and future directions. Key factors influencing outcomes, including the timeliness of intervention and the choice between limb salvage and amputation, are identified. Moreover, this review underscores the importance of early detection and multidisciplinary care, emphasising the significance of patient-centred approaches. It also calls for increased awareness, continued research, and innovative solutions to improve the lives of individuals grappling with gangrene in the context of PVD.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

P-056 ELECTIVE OPEN INGUINAL HERNIA REPAIRS- ARE WE DISCLOSING ALL THE RISKS?

Introduction and Aim

Elective open inguinal hernia repairs are one of the most common procedures carried out in the NHS with over 78000 operations per year. There are many risks associated with this procedure and so obtaining informed consent is imperative to patient care and patient choice. The aim of this study is to compare the quality of consent forms for elective open inguinal hernia repairs to the guidance provided by the Royal College of Surgeons (RCS) and the British Hernia Society (BHS).

Method

60 patients (50 male, 10 female) undergoing elective open inguinal hernia repair between 01/09/2021–20/12/2021 were identified retrospectively. Their consent forms were audited against modified guidelines from RCS and BHS. The grade of the consenting surgeon was also noted.

Results

Sepsis (95%), recurrence (85%), and chronic pain (82%) were the most consented risks. Least consented serious risks were persistent numbness (47%), nerve injury (47%), and mesh infection (40%). Notable disparities existed between rates of consent and grade of surgeon: 64% of registrars consented for nerve injury compared to 9% of SHOs and 82% of SHOs consented for haematoma compared to 20% of consultants.

Conclusion

Serious risks such mesh infection and nerve injury were often missed from consent forms. There is inconsistency in consented risks between different grades of surgeon. A standardised consent form would improve consent consistency and potentially reduce rate of litigation for doctors and the trust. Comprehensive pre-made consent forms were therefore designed to better facilitate a standardised approach to the consenting process.

Physical activity recommendations pre and post abdominal wall reconstruction: a scoping review of the evidence

PURPOSE

There are no universally agreed guidelines regarding which types of physical activity are safe and/or recommended in the perioperative period for patients undergoing ventral hernia repair or abdominal wall reconstruction (AWR). This study is intended to identify and summarise the literature on this topic.

METHODS

Database searches of PubMed, CINAHL, Allied & Complementary medicine database, PEDro and Web of Science were performed followed by a snowballing search using two papers identified by the database search and four hand-selected papers of the authors' choosing. Inclusion-cohort studies, randomized controlled trials, prospective or retrospective. Studies concerning complex incisional hernia repairs and AWRs including a "prehabilitation" and/or "rehabilitation" program targeting the abdominal wall muscles in which the interventions were of a physical exercise nature. RoB2 and Robins-I were used to assess risk of bias. Prospero CRD42021236745. No external funding. Data from the included studies were extracted using a table based on the Cochrane Consumers and Communication Review Group's data extraction template.

RESULTS

The database search yielded 5423 records. After screening two titles were selected for inclusion in our study. The snowballing search identified 49 records. After screening one title was selected for inclusion in our study. Three total papers were included-two randomised studies and one cohort study (combined 423 patients). All three studies subjected their patients to varying types of physical activity preoperatively, one study also prescribed these activities postoperatively. The outcomes differed between the studies therefore meta-analysis was impossible-two studies measured hernia recurrence, one measured peak torque. All three studies showed improved outcomes in their study groups compared to controls however significant methodological flaws and confounding factors existed in all three studies. No adverse events were reported.

CONCLUSIONS

The literature supporting the advice given to patients regarding recommended physical activity levels in the perioperative period for AWR patients is sparse. Further research is urgently required on this subject.

Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital?

AIMS

Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy.

MATERIALS AND METHODS

Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews.

RESULTS

Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022).

CONCLUSION

This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.

Glue versus mechanical mesh fixation in laparoscopic inguinal hernia repair: meta-analysis and trial sequential analysis of randomized clinical trials

BACKGROUND

The optimal choice for mesh fixation in laparoscopic inguinal hernia repair (LIHR) has not been well established. This review compared the effects of glue versus mechanical mesh fixation in LIHR on incidence of chronic postoperative inguinal pain (CPIP) and other secondary outcomes, including acute pain, seroma, haematoma, hernia recurrence and other postoperative complications.

METHODS

A systematic review of English/non-English studies using MEDLINE, the Cochrane Library, OpenGrey, OpenThesis and Web of Science, and searching bibliographies of included studies was completed. Search terms included laparoscopic, hernia, fibrin glue, Tisseel, Tissucol, cyanoacrylate, Glubran and Liquiband. Only RCTs comparing mechanical with glue-based fixation in adult patients (aged over 18 years) that examined CPIP were included. Two authors independently completed risk-of-bias assessment and data extraction against predefined data fields. All pooled analyses were computed using a random-effects model.

RESULTS

Fifteen RCTs met the inclusion criteria; 2777 hernias among 2109 patients were assessed. The incidence of CPIP was reduced with use of glue-based fixation (risk ratio (RR) 0.36, 95 per cent c.i. 0.19 to 0.69; P = 0.002), with moderate heterogeneity that disappeared with sensitivity analysis (8 d.f.) for patient-blinded studies (RR 0.43, 0.27 to 0.86). Trial sequential analysis provided evidence for a relative risk reduction of at least 25 per cent. The incidence of haeamtoma was reduced by using glue-based fixation (RR 0.29, 0.10 to 0.82; P = 0.02) with no significant effects on seroma formation or hernia recurrence (RR 1.07, 0.46 to 2.47; P = 0.88).

CONCLUSION

Glue-based mesh fixation appears to reduce the incidence of CPIP and haematoma after LIHR compared with mechanical fixation, with comparable recurrence rates.

TB in Indian adolescents: results from a nationally representative survey, 2015-2016

SETTING: Adolescents (age: 15-19 years) from the National Family Health Survey-4 (2015-2016), India.OBJECTIVE: To examine the sociodemographic and nutritional characteristics of adolescents with reported TB and those with a reported household TB exposure.METHODS: This was a cross-sectional study using secondary data. We assessed the factors associated with TB (reported in adolescents, or in a household member) using log binomial regression. We used height-for-age and body mass index for age Z-scores for stunting and thinness, respectively.RESULTS: Of the total 277 059 adolescents, 377 (136/100 000, 95%CI 123-151) were reported with TB and this was similar in both sexes. Another 4528 adolescents (1.6%, 95%CI 1.6-1.7) reported household TB exposure. Poverty and urban residence were associated with higher prevalence of TB and household TB exposure. The proportion of stunting was 40.7% (95%CI 33.5-48.0) in adolescents with reported TB and 38.2% (95%CI 36.2-40.2) (P = 0.248) in those with household TB exposure.CONCLUSION: Prevalence of reported adolescent TB was lower than adult TB. Poverty and urban residence were risk factors for both TB and household TB exposure. Chronic undernutrition was highly prevalent among those reported to have TB and in those at risk of TB by virtue of having household TB exposure.

The nucleus acts as a ruler tailoring cell responses to spatial constraints

The microscopic environment inside a metazoan organism is highly crowded. Whether individual cells can tailor their behavior to the limited space remains unclear. In this study, we found that cells measure the degree of spatial confinement by using their largest and stiffest organelle, the nucleus. Cell confinement below a resting nucleus size deforms the nucleus, which expands and stretches its envelope. This activates signaling to the actomyosin cortex via nuclear envelope stretch-sensitive proteins, up-regulating cell contractility. We established that the tailored contractile response constitutes a nuclear ruler-based signaling pathway involved in migratory cell behaviors. Cells rely on the nuclear ruler to modulate the motive force that enables their passage through restrictive pores in complex three-dimensional environments, a process relevant to cancer cell invasion, immune responses, and embryonic development.

How much do Indians pay for tuberculosis treatment? A cost analysis

Setting

India's National Tuberculosis Elimination Programme (NTEP) covers diagnostic and therapeutic costs of TB treatment. However, persons living with TB (PLWTB) continue to experience financial distress due to direct costs (payment for testing, treatment, travel, hospitalization, and nutritional supplements) and indirect costs (lost wages, loan interest, and cost of domestic helpers).

Objective

To analyze the magnitude and pattern of TB-related costs from the perspective of Indian PLWTB.

Design

We identified relevant articles using key search terms ('tuberculosis,' 'India,' 'cost,' 'expenditures,' 'financing,' 'catastrophic' and 'out of pocket') and calculated variance-weighted mean costs.

Results

Indian patients incur substantial direct costs (mean: US$46.8). Mean indirect costs (US$666.6) constitute 93.4% of the net costs. Mean direct costs before diagnosis can be up to four-fold that of costs during treatment. Treatment in the private sector can result in costs up to six-fold higher than in government facilities. As many as one in three PLWTB in India experience catastrophic costs.

Conclusion

PLWTB in India face high direct and indirect costs. Priority interventions to realize India's goal of eliminating catastrophic costs from TB include decreasing diagnostic delays through active case finding, reducing the need for travel, improving awareness and perception of NTEP services, and ensuring sufficient reimbursement for inpatient TB care.

The Antimicrobial Properties of Chitosan Can be Tailored by Formulation

Topical administration of drugs into the vagina can provide local therapy of vaginal infections, preventing the possible systemic side effects of the drugs. The natural polysaccharide chitosan is known for its excellent mucoadhesive properties, safety profile, and antibacterial effects, and thus it can be utilized in improving localized vaginal therapy by prolonging the residence time of a drug at the vaginal site while acting as an antimicrobial in synergy. Therefore, we aimed to explore the potential of chitosan, namely chitosan-coated liposomes and chitosan hydrogel, as an excipient with intrinsic antimicrobial properties. Liposomes were prepared by the thin-film hydration method followed by vesicle size reduction by sonication to the desired size, approximately 200 nm, and coated with chitosan (0.01, 0.03, 0.1, and 0.3%, w/v, respectively). The mucoadhesive properties of chitosan-coated liposomes were determined through their binding efficiency to mucin compared to non-coated liposomes. Non-coated liposomal suspensions were incorporated in chitosan hydrogels forming the liposomes-in-hydrogel formulations, which were further assessed for their texture properties in the presence of biological fluid simulants. The antibacterial effect of chitosan-coated liposomes (0.03%, 0.1% and 0.3%, w/v) and chitosan hydrogels (0.1% and 0.3%, w/w) on Staphylococcus epidermidis and Staphylococcus aureus was successfully confirmed.

Retinal burns from laser pointers: a risk in children with behavioural problems

OBJECTIVE

To explore self-inflicted retinal burns from laser pointers in children.

METHODS

Literature review of laser pointer retinal injuries in childhood and online survey of UK Consultant Ophthalmologists. A cohort of local children with self-inflicted injury is described. The matter is topical. We review progress in recent legislation and policy change in the UK.

RESULTS

Four of 77 case reports of laser burns in childhood analysed reported psychological or behavioural issues. Three of four children in our cohort had such issues. Delay in diagnosis occurred in two of our patients. Structural retinal damage persisted for over 12 months in all four children (seven eyes). Our survey of UK ophthalmologists found 159 cases of injury (85% male), 80% under 20 years of age. The majority of the laser pointers were purchased online. Many patients (36%) suffered moderate vision loss (6/18 to 6/60 Snellen), while 17% (at least 11 patients) suffered severe vision loss (<6/60 Snellen).

CONCLUSION

We highlight the risk of macular damage and vision loss from handheld lasers specifically in children with behavioural, learning or mental health issues. The diagnosis may be difficult or delayed in such children. In children with uncertain macular changes, ophthalmologists should explore the history for possible instances of exposure to handheld lasers pointers. Regulatory authorities and manufacturers of handheld lasers need to be aware of the risk to children. Furthermore, there is a need to better inform parents, carers and teachers of the risk of ocular self-injury from such lasers pointers.

Nutritional assessment and counselling of tuberculosis patients at primary care in India: do we measure up?

SETTING

Dakshina Kannada District, coastal South India, under the Revised National Tuberculosis Control Programme (RNTCP).

OBJECTIVE

To identify the potential and practices at primary health centres (PHCs) for the assessment of nutritional status of patients with tuberculosis (TB), the basic tools used to measure height and weight and the type of nutritional counselling provided.

DESIGN

A cross-sectional study was conducted with physical verification of availability of height and weight measuring equipment. Information was collected on the method used by medical officers for assessing nutritional status in PHCs, action taken in case the patient is undernourished and any formal training in nutritional assessment and counselling.

RESULTS

Of 37 PHCs assessed, weighing machines were available in all and stadiometers in 38%. Medical officers were not calculating body mass index for nutritional assessment even when height and weight were being uniformly measured. Nutritional classification was mostly based on the appearance and physique of the patient. Counselling included advice to take milk, eggs and protein powders with efforts to arrange funds from village health, sanitation and nutrition committees.

CONCLUSION

There is a need to equip the PHCs and their medical officers with necessary tools and training for nutritional assessment and counselling of patients with tuberculosis.

Evaluating the Role of Immunological Cells (Tissue Eosinophils and Mast Cells) in Progression of Oral Squamous Cell Carcinoma

Mast cells and eosinophils are increased in oral squamous cell carcinoma. The significance of such an association has been variably thought to be either a potential diagnostic tool for stromal invasion or as a prognostic indicator. The aim of the study was to study the mast cells and eosinophils between normal oral mucosa, leukoplakia and oral squamous cell carcinoma and to study the significance of mast cells in the progression of the lesion. A retrospective study was done on archival tissue received from January 2015 to December 2015, in the Department of Oral Pathology, RUHS College of Dental Sciences, Jaipur, Rajasthan, India. Seventy (70) cases were studied (30 cases each of leukoplakia and carcinoma and 10 cases of control group), sections were stained with toluidine blue solution to reveal mast cells. Eosinophils were studied in Haematoxylin & Eosin stained sections. Mast cell density significantly increased from: normal mucosa to oral leukoplakia to carcinoma, suggesting a role of the mast cells in the development of these lesions. The higher eosinophil counts in carcinoma group compared to dysplasia group proved that they might have a role in stromal invasion. The assessment of these could become, in the future, useful for therapeutic approaches in this subset of the patient.

Early-life adversity, epigenetics, and visceral hypersensitivity

Abdominal pain is associated with many gastrointestinal dysfunctions, such as irritable bowel syndrome (IBS), functional dyspepsia, and inflammatory bowel disease (IBD). Visceral hypersensitivity is a key reason for development of abdominal pain that presents in these gastrointestinal disorders/diseases. The pathogenesis of visceral hypersensitivity is complex and still far from being fully understood. In animal studies, visceral hypersensitivity has been linked to several early-life adverse (ELA) events. In humans, IBD, functional dyspepsia, and IBS can have adult onset, though the adverse events that lead to visceral hypersensitivity are largely uncharacterized. In this issue of the journal, Aguirre et al. report the interesting finding that epigenetics underlies the effects of ELA events on visceral hypersensitivity. This mini-review examines models of ELA events leading to visceral hypersensitivity and the potential role of epigenetics, as reported by Aguirre et al. and others.

Similar HbA1c reduction and hypoglycaemia with variable- vs fixed-time dosing of basal insulin peglispro in type 1 diabetes: IMAGINE 7 study

AIMS

To compare 24-hour fixed-time basal insulin peglispro (BIL) dosing with 8- to 40-hour variable-time BIL dosing for glycaemic control and safety in patients with type 1 diabetes. Primary outcome was non-inferiority of BIL variable-time dosing compared with fixed-time dosing for glycated haemoglobin (HbA1c) change after 12-week treatment (margin = 0.4%).

MATERIALS AND METHODS

This Phase 3, open-label, randomized, cross-over study (N = 212) was conducted at 20 centres in the United States. During the 12-week lead-in phase, patients received BIL daily at fixed-times. Two 12-week randomized cross-over treatment phases followed, where patients received BIL dosed at either fixed- or variable-times. During the 4-week safety follow-up, patients received conventional insulins.

RESULTS

During the lead-in period, least-squares mean HbA1c decreased from 7.5% to 6.8%. For BIL, variable-time dosing was non-inferior to fixed-time dosing for HbA1c change [least-squares mean difference = 0.06%, 95% confidence interval (-0.01, 0.13)]. In both regimens, HbA1c increased slightly during the cross-over periods, but remained significantly below baseline. Variable- and fixed-time dosing regimens had similar rates of total hypoglycaemia (10.4 ± 0.62 and 10.5 ± 0.67 events/patient/30 days, P = .947) and nocturnal hypoglycaemia (1.3 ± 0.11 and 1.5 ± 0.13 events/patient/30days, P = .060). Comparable proportions of patients achieved HbA1c < 7.0% with variable- [91 (54.5%)] and fixed-time dosing [101 (60.5%)].

CONCLUSIONS

Treatment with BIL allows patients to use flexible dosing intervals from 8 to 40 hours. Glycaemic efficacy (HbA1c), glycaemic variability and hypoglycaemia are similar to fixed-time dosing, suggesting that BIL could potentially provide flexibility in dosing for patients who miss their daily basal insulin.

Superior Mesenteric Artery Syndrome: Diagnosis and Management

Superior mesenteric artery syndrome is a life-threatening rare acquired upper gastrointestinal disorder due to mechanical compression of third part of duodenum by the acute angulation of Superior mesenteric artery, leading to obstruction. Acute loss of intervening mesenteric fat as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the reduced aortomesenteric angle. Abdominal CT angiography showed the dilatation of second part of duodenum and vascular compression of the proximal third part of the duodenum between the aorta and superior mesenteric artery. We report a case of 15 year old young boy who presented with recurrent postprandial pain in the epigastric region, accompanied by epigastric fullness, nausea, postprandial bilious vomiting and weight loss. When conservative measures were ineffective, laparoscopic retrocolic duodenojejunostomy, side to side anastomosis, was performed in the patient to relieve the obstruction. This case report is unusual as it is concerned with the description of a rare disease entity and its radiological appearances for early preoperative diagnosis, better understanding and management of the disease are discussed in the pertinent light of literature.

Outcomes of paired-exchange live-donor kidney transplantation: a single-center experience

INTRODUCTION

Paired-exchange kidney transplantation (PEKT) enables recipients with willing but incompatible donors to find potential matches from a larger pool of donors. It involves transportation of donor kidneys to the intended recipient with a consequent increase in the cold ischemia time (CIT).

PATIENTS AND METHODS

Our single-center study compared the outcomes of PEKT versus traditional in-center live-donor kidney transplants (ICKT). Retrospective chart review of adult patients who underwent PEKT and ICKT from January 2009 to February 2012 at our institution was performed. Delayed graft function, acute rejection rates, incidence of proteinuria, trends in serum creatinine, and graft and patient survival rates were compared between groups.

RESULTS

Baseline demographic data were similar between the PEKT group (n = 15) and the ICKT group (n = 30) except that CIT (13.1 vs 3.8 hours; P < .001) and panel reactive antibody titers (12.6% ± 22.9% vs 0.9% ± 4.9%; P = .01) were significantly higher in the PEKT group. No patient developed delayed graft function. At a median follow-up of 12.4 months (range: 2-27.5 months), graft and patient survival rates were 100% in both groups. Serial creatinine levels were similar between the groups. There were no significant differences between groups in acute rejection rates (3 of 15 vs 3 of 30) and development of proteinuria posttransplantation (8 of 15 vs 22 of 30).

CONCLUSIONS

Our study found similar outcomes between the PEKT and ICKT groups despite longer CIT and higher panel reactive antibody titers in the PEKT group. These findings support the current practice of PEKT with transporting of donor kidneys, with the resultant increase in the chances of living-donor kidney transplantation.

Similar efficacy and safety of LY2963016 insulin glargine and insulin glargine (Lantus®) in patients with type 2 diabetes who were insulin-naïve or previously treated with insulin glargine: a randomized, double-blind controlled trial (the ELEMENT 2 study)

AIMS

To compare the efficacy and safety of LY2963016 insulin glargine (LY IGlar) and the reference product (Lantus(®)) insulin glargine (IGlar) in combination with oral antihyperglycaemic medications in patients with type 2 diabetes (T2D).

METHODS

This phase III, randomized, double-blind, 24-week study enrolled patients with T2D who were insulin-naïve [glycated haemoglobin (HbA1c) ≥7 and ≤11.0%] or previously on IGlar (HbA1c ≤11%) and treated with ≥2 oral antihyperglycaemic medications. Patients were randomized to receive once-daily LY IGlar (n = 376) or IGlar (n = 380) for 24 weeks. The primary efficacy outcome was to test the non-inferiority (0.4% and then 0.3% margin) of LY IGlar to IGlar, as measured by change in HbA1c from baseline to 24 weeks.

RESULTS

Both treatment groups had similar and significant (p < 0.001) within-group decreases in mean HbA1c values from baseline. LY IGlar met non-inferiority criteria compared with IGlar for change in HbA1c from baseline [-1.29 vs -1.34%; respectively, least-squares mean difference 0.052% (95% confidence interval -0.070 to 0.175); p > 0.05]. There were no treatment differences (p > 0.05) in fasting plasma glucose, proportion of patients reaching HbA1c <7% or insulin dose at 24 weeks. Adverse events, allergic reactions, weight change, hypoglycaemia and insulin antibodies were similar between treatment groups. Similar findings were observed in patients who were insulin-naïve or previously treated with IGlar at baseline.

CONCLUSIONS

Both LY IGlar and IGlar, when used in combination with oral antihyperglycaemic medications, provided effective and similar glucose control with similar safety profiles in patients with T2D.

Outcome of carpal tunnel release--correlation with wrist and wrist-palm anthropomorphic measurements

Wrist and wrist-palm measurements have been associated with the diagnosis of carpal tunnel syndrome. We found no reported study about how this correlation affects the outcome after surgery. We investigated the role of the measurements in predicting outcome after open carpal tunnel release. A total of 131 patients (88 female, 43 male) responded to our postal questionnaire using the Boston Carpal Tunnel assessment (65% response rate) at a minimum of 9 months post-operatively. Symptom and functional scores showed a strong correlation. There was no statistical difference in the outcome between wrist ratio (≥0.7 vs <0.7), wrist-palm ratio (≥0.41 vs <0.41) and gender, but a better functional score was very weakly correlated with a higher wrist ratio. A very large study would be needed to show any statistical correlation between both measurement and outcome.

Mechanisms linked to differences in the mutagenic potential of 1,3-dinitropyrene and 1,8-dinitropyrene

This study explores and characterizes the toxicity of two closely related carcinogenic dinitro-pyrenes (DNPs), 1,3-DNP and 1,8-DNP, in human bronchial epithelial BEAS-2B cells and mouse hepatoma Hepa1c1c7 cells. Neither 1,3-DNP nor 1,8-DNP (3–30 μM) induced cell death in BEAS-2B cells. In Hepa1c1c7 cells only 1,3-DNP (10–30 μM) induced a mixture of apoptotic and necrotic cell death after 24 h. Both compounds increased the level of reactive oxygen species (ROS) in BEAS-2B as measured by CM-H₂DCFDA-fluorescence. A corresponding increase in oxidative damage to DNA was revealed by the formamidopyrimidine-DNA glycosylase (fpg)-modified comet assay. Without fpg, DNP-induced DNA damage detected by the comet assay was only found in Hepa1c1c7 cells. Only 1,8-DNP formed DNA adduct measured by ³²P-postlabelling. In Hepa1c1c cells, 1,8-DNP induced phosphorylation of H2AX (γH2AX) and p53 at a lower concentration than 1,3-DNP and there was no direct correlation between DNA damage/DNA damage response (DR) and induced cytotoxicity. On the other hand, 1,3-DNP-induced apoptosis was inhibited by pifithrin-α, an inhibitor of p53 transcriptional activity. Furthermore, 1,3-DNP triggered an unfolded protein response (UPR), as measured by an increased expression of CHOP, ATF4 and XBP1. Thus, other types of damage possibly linked to endoplasmic reticulum (ER)-stress and/or UPR could be involved in the induced apoptosis. Our results suggest that the stronger carcinogenic potency of 1,8-DNP compared to 1,3-DNP is linked to its higher genotoxic effects. This in combination with its lower potency to induce cell death may increase the probability of causing mutations.

Revisiting peripheral osteoma of the mandible with case series and review of literature

Osteomas are benign lesions composed of mature compact and cancellous bone usually arising from craniofacial region. They can be central or peripheral, solitary or multiple. We are presenting few cases of giant peripheral osteoma's of the mandible along with review literature of other jaw lesions with their diagnostic features and differential diagnosis. The purpose of presenting this paper is to evaluate radiopaque lesions of the jaw which require proper clinical and histological evaluation to reach a final diagnosis.

The effect of pioglitazone and extended-release niacin on HDL-cholesterol in diabetes patients in a real-world setting

OBJECTIVE

This retrospective study was designed to assess the effects of the combination of pioglitazone and extended-release niacin on the lipid panel, particularly HDL-cholesterol, when used in patients with type 2 diabetes in an endocrinology specialty practice.

METHODS

The electronic medical records of 434 adult patients with type 2 diabetes receiving extended-release niacin and pioglitazone were screened for review. Patients with type 2 diabetes and hyperlipidemia were included for review if they received the combination of pioglitazone at doses ≥ 15 mg/day and extended-release niacin (Niaspan) at doses ≥ 1000 mg/day for ≥6 months. Statistical analysis used paired t-tests with p < 0.05 as statistically significant. Both ANOVA and the Tukey-Kramer test for multiple comparisons (α = 0.05) were also used.

RESULTS

A total of 47 patients, 83% were men with average age of 58, met all eligibility criteria for the study. Compared with baseline, a statistically significant increase in HDL-C (+ 25.13%, p < 0.0001) was observed at the conclusion of combination therapy. The HDL-C levels progressively increased with duration of combination treatment, and were not correlated with concomitant statin use. Significant decreases in total cholesterol and triglycerides were detected, and HbA1c decreased 0.84% during combination therapy for all therapies combined.

CONCLUSION

The combination of pioglitazone and extended-release niacin in patients with type 2 diabetes and hyperlipidemia, used in commonly prescribed doses for at least 6 months, resulted in statistically significant improvements in HDL-C, total cholesterol, and triglycerides, and did not result in deteriorations in glycemic control.

Effect of insulin degludec versus sitagliptin in patients with type 2 diabetes uncontrolled on oral antidiabetic agents

AIM

The efficacy and safety of insulin degludec (IDeg), a new basal insulin with an ultra-long duration of action, was compared to sitagliptin (Sita) in a 26-week, open-label trial.

METHODS

Insulin-naïve subjects with type 2 diabetes [n = 458, age: 56 years, diabetes duration: 7.7 years, glycosylated haemoglobin (HbA1c): 8.9% (74 mmol/mol)] were randomized (1 : 1) to once-daily IDeg or Sita (100 mg orally) as add-on to stable treatment with 1 or 2 oral antidiabetic drugs (OADs).

RESULTS

Superiority of IDeg to Sita in improving HbA1c and fasting plasma glucose (FPG) was confirmed [estimated treatment difference (ETD) IDeg-Sita for HbA1c: -0.43%-points [95% confidence interval (CI): -0.61; -0.24, p < 0.0001] and for FPG: -2.17 mmol/l (95% CI: -2.59; -1.74, p < 0.0001)]. HbA1c < 7% (<53 mmol/mol) was achieved by 41% (IDeg) versus 28% (Sita) of patients, estimated odds ratio IDeg/Sita: 1.60 (95% CI: 1.04; 2.47, p = 0.034). There was no statistically significant difference in the rate of nocturnal confirmed hypoglycaemia between IDeg and Sita [0.52 vs. 0.30 episodes/patient-year, estimated rate ratio (ERR): IDeg/Sita: 1.93 (95% CI: 0.90; 4.10, p = 0.09)]. Rates of overall confirmed hypoglycaemia were higher with IDeg than with Sita [3.1 vs. 1.3 episodes/patient-year, ERR IDeg/Sita: 3.81 (95% CI: 2.40; 6.05, p < 0.0001)]. IDeg was associated with a greater change in body weight than Sita [ETD IDeg-Sita: 2.75 kg (95% CI: 1.97; 3.54, p < 0.0001)]. The overall rates of adverse events were low and similar for both groups.

CONCLUSIONS

In patients unable to achieve good glycaemic control on OAD(s), treatment intensification with IDeg offers an effective, well-tolerated alternative to the addition of a second or third OAD.

Formulation and in vitro evaluation of floating tablets of hydroxypropyl methylcellulose and polyethylene oxide using ranitidine hydrochloride as a model drug

The present study was carried out with an objective of preparation and in vitro evaluation of floating tablets of hydroxypropyl methyl cellulose (HPMC) and polyethylene oxide (PEO) using ranitidine hydrochloride as a model drug. The floating tablets were based on effervescent approach using sodium bicarbonate a gas generating agent. The tablets were prepared by dry granulation method. The effect of polymers concentration and viscosity grades of HPMC on drug release profile was evaluated. The effect of sodium bicarbonate and stearic acid on drug release profile and floating properties were also investigated. The result of in vitro dissolution study showed that the drug release profile could be sustained by increasing the concentration of HPMC K15MCR and Polyox WSR303. The formulation containing HPMC K15MCR and Polyox WSR303 at the concentration of 13.88% showed 91.2% drug release at the end of 24 hours. Changing the viscosity grade of HPMC from K15MCR to K100MCR had no significant effect on drug release profile. Sodium bicarbonate and stearic acid in combination showed no significant effect on drug release profile. The formulations containing sodium bicarbonate 20 mg per tablet showed desired buoyancy (floating lag time of about 2 minutes and total floating time of >24 hours). The present study shows that polymers like HPMC K15MCR and Polyox WSR303 in combination with sodium bicarbonate as a gas generating agent can be used to develop sustained release floating tablets of ranitidine hydrochloride.

Progeria: pathogenesis and oral manifestation--a review

Our life span is genetically programmed and it is possible that a defect in produced proteins encoded by the longevity gene is a cause of aging. Progeria which is a rare, fatal genetic condition which affects between one in four million and one in eight million children of both sexes equally and characterized by premature and accelerated aging. The appearance and physiology of these children resembles to elderly people but they typically have life span to their mid teens. It is also known as the Hutchinson-Gilford syndrome, which was initially reported by Johnathan Hutchinson in 1886 and further described by Hastings Gilford in 1904. It is an autosomal recessive disorder, which means an individual has inherited a mutated gene from both parents. It is added to the expanding catalogue of laminopathies, diseases caused by mutations affecting nuclear lamina proteins known as lamin A (LMNA). In oral manifestation primary finding is micrognathia with delayed tooth eruption and incomplete formation of root of permanent tooth. Presently there are no known cures for this abnormality.

Prevalence of hepatitis C virus genotypes and impact of T helper cytokines in achieving sustained virological response during combination therapy: a study from Central India

Characterisation of host immune response to hepatitis C virus (HCV) genotypes may have an important prognostic and therapeutic implication. Genotype-3 was more prevalent in the examined cohort and demonstrated a significantly higher response to combination therapy than genotype-1. Sustained virological response (SVR) was 94.74% in genotype-3 and 45.45% in genotype-1. The patients who achieved SVR reported higher levels of circulating T helper 1 cytokines in comparison to subjects with no SVR in both the studied groups. Besides providing local prevalence, our study might also assist in understanding the host immune mechanisms involved to achieve SVR during combination therapy in chronic HCV patients.

Studies on in vitro antioxidant and antistaphylococcal activities of some important medicinal plants

Oxidative stress is initiated by free radicals, which seek stability through electron pairing with biological macromolecules in healthy human cells and cause protein and DNA damage along with lipid peroxidation. Many phytochemicals have been found to play as potential antioxidants and antimicrobials. In the present study antioxidant and antistaphylococcal activities of Bauhinia variegata, Tinospora cardifolia and Piper longum have been determined. Total phenolic contents in plant extracts were estimated and different amounts of phenolic contents were found in B. variegata, T. cardifolia and P. longum extracts. The antioxidant activity of the extracts was compared with standard antioxidants such as, BHA, BHT, quercetin, ascorbic acid and propyl gallate. The % scavenging activity gradually increased with increasing concentrations of the test extracts in DPPH radical scavenging assay. Dose dependent antioxidant activity pattern was also observed in phosphomolybdate assay. Antioxidant activity was directly correlated with the amount of total phenolic contents in the extracts. As compared to B. variegata, the extracts from other two plants exhibited higher antioxidant activity. In disc diffusion assays several solvent extracts derived from test plants inhibited the growth of Staphylococcus aureus. Maximum inhibitory efficacy was observed in T. cardifolia extracts. However, the lowest minimum bactericidal concentration (MBC) (0.43 mg/ml) was recorded for ethyl acetate and acetone extracts of P. longum. This study demonstrates notable antioxidant and anti-staphylococcal roles assigned to some plant extracts tested.

c-Jun NH2-terminal kinase-2 mediates osmotic stress-induced tight junction disruption in the intestinal epithelium

Gastrointestinal epithelium faces osmotic stress, both at physiological and pathophysiological conditions. JNK activation is an immediate cellular response to osmotic stress. We investigated the effect of osmotic stress on intestinal epithelial barrier function and delineated the role of JNK2 in osmotic stress-induced tight junction (TJ) regulation in Caco-2 cell monolayers and ileum of Jnk(-/-) and Jnk2(-/-) mice. The role of JNK activation in osmotic stress-induced TJ disruption was evaluated using JNK-specific inhibitor and antisense oligonucleotides. Furthermore, the effect of cold restraint stress in vivo on TJ integrity was determined in rats. Osmotic stress disrupted TJs and barrier function in Caco-2 cell monolayers without affecting cell viability. Osmotic stress activated JNK1 and JNK2 and the inhibition of JNK by SP600125 attenuated osmotic stress-induced TJ disruption. TJ disruption and barrier dysfunction by osmotic stress was associated with JNK-dependent remodeling of actin cytoskeleton. Knockdown of JNK2 accelerated TJ assembly and attenuated osmotic stress-induced TJ disruption in Caco-2 cell monolayers. In mouse ileum in vitro, osmotic stress increased paracellular permeability, which was attenuated by SP600125. Osmotic stress disrupted actin cytoskeleton and TJs and increased paracellular permeability in the ileum of wild-type and JNK1(-/-) mice, but not in JNK2(-/-) mouse ileum. Cold restraint stress activated JNK in rat ileum and caused JNK-dependent remodeling of actin cytoskeleton and redistribution of occludin and zona occluden-1 from the intercellular junctions. These results reveal the role of JNK2 in the mechanism of osmotic stress-induced TJ disruption in the intestinal epithelium.

Diagnosis of gastrointestinal tuberculosis: Using cytomorphological, microbiological, immunological and molecular techniques - A study from Central India

The present study included three groups: (A) age and gender matched control (n=24) with no previous signs of M. tuberculosis complex (MTBC) infection, (B) patients (n=28) diagnosed with gastro-intestinal TB (GITB), (C) patients (n=50) with clinical and histo-pathological signs of GITB, but were culture and AFB negative. Real time assay performed using fluorescence resonance energy transfer hybridization probes showed a positivity index of 36 % in group C, i.e. 18 were found reactive from the total 50 cases studied. In addition, immune characterization of these 18 cases showed depleted CD(4) (+) count and increased levels of IFN-γ and TNF-α cytokines. No positive case was found in group A, while in group B, out of total 28 cases studied 27 were found positive. A combinatorial diagnostic approach for rapid detection and characterization of GITB might provide specific therapeutic strategies for prevention and treatment of the infection in future.

Remission of paroxysmal atrial fibrillation with iron reduction in haemophilia A

SUMMARY

Two male first cousins with mild haemophilia A had baseline factor VIII levels of 12-15% and experienced bleeding requiring coagulation factor infusion therapy with trauma and surgical procedures. Both the patients with haemophilia A also had electrocardiographically documented symptomatic paroxysmal atrial fibrillation (PAF) for several years that had become resistant to pharmacological suppression. Radiofrequency ablation was considered in both the cases but deferred considering refusal of consent by the patients to undergo the procedure. Remission of arrhythmias has been reported in patients with iron-overload syndromes. Body iron stores assessed by serum ferritin levels were elevated in both men but neither had the C282Y or H63D genes for haemochromatosis. Calibrated reduction of iron stores by serial phlebotomy, avoiding iron deficiency, was followed by remission of symptomatic PAF in both cases. Iron reduction may be an effective treatment for arrhythmias apart from the classic iron-overload syndromes and deserves further study particularly in patients with bleeding disorders who might be at risk for arrhythmias and other diseases of ageing.

Synthesis, antibacterial and antiviral properties of curcumin bioconjugates bearing dipeptide, fatty acids and folic acid

Curcumin bioconjugates, viz. di-O-tryptophanylphenylalanine curcumin (2), di-O-decanoyl curcumin (3), di-O-pamitoyl curcumin (4), di-O-bis-(γ,γ)folyl curcumin (6), C⁴-ethyl-O-γ-folyl curcumin (8) and 4-O-ethyl-O-γ-folyl curcumin (10) have been synthesized and tested for their antibacterial and antiviral activities. The conjugates 2, 3, 4, 6 and 8 have shown very promising antibacterial activity with MIC ranging between 0.09 and 0.67 μM against Gram-positive cocci and Gram-negative bacilli. Further, the conjugates 2, 3, 6, 8 and 10 have been screened for their antiviral activities against HSV, VSV, FIPV, PIV-3, RSV and FHV and the molecules 2 and 3 have shown good results with EC₅₀ 0.011 μM and 0.029 μM against VSV and FIPV/FHV, respectively. However, the molecules did not show expected results against HIV-1 III_B and ROD strains in MTT assay.