The role of platelet-rich plasma in androgenetic alopecia: A systematic review

BACKGROUND

Androgenetic alopecia (AGA), also referred to as male or female pattern hair loss, is the commonest cause of chronic hair loss and affects up to 80% of men by the age of 70. Despite a high prevalence, there are few approved therapies, which show minimal efficacy.

OBJECTIVES

This systematic review aims to evaluate the efficacy of platelet-rich plasma (PrP) in the treatment of AGA in male patients.

METHODS

MEDLINE, EMBASE, Cochrane (CENTRAL), CINAHL, clinicaltrials.gov, Google Scholar and the Science Citation Index database were searched to identify eligible studies. All randomized controlled trials (RCTs) and prospective cohort studies related to PrP use in AGA were included. Primary outcomes included changes in hair density and hair count. Methodological quality was assessed using bias assessment tools.

RESULTS

Eight RCTs and one cohort study were included in the review with a total of 291 participants. Six studies reported a statistically significant increase in hair density in the PrP group versus the control. Five studies reported a statistically significant increase in hair count with PrP. Seven studies showed moderate risk and two showed low risk of bias.

CONCLUSION

In a methodologically robust review on the effectiveness of PrP on male AGA, PrP demonstrated some potential to be used therapeutically. However, the low quality of evidence, moderate risk of bias, and high heterogeneity of included studies limit inferences and call for more robust designs to investigate this further.

592 Surgical Management of Open Tibia Fractures at A Major Trauma Centre: A Review of Cases Over A One-Year Period

Introduction

The BOAST/BAPRAS updated the open fracture guidelines in December 2017 to replace BOAST 4 Open fracture guidelines; the changes gave clearer recommendations for timing of surgery and recommendations for reducing infection rates.

Method

Our work retrospectively evaluates the surgical management of open tibia fractures at a Major Trauma Centre (MTC), over a one-year period in light of key standards (13,14 and 15 of the standards for open fractures).

Results

The vast majority of cases (93%) had definitive internal stabilization only when immediate soft tissue coverage was achievable. 90% of cases were not managed as ‘clean cases’ following the initial debridement. 50% of cases underwent definitive closure within 72 hours. The reasons for definitive closure beyond 72hours were: patients medically unwell (20%), multiple wound debridement’s (33%) and no medical or surgical reason was clearly stated (47%).

Conclusions

The implementation of a ‘clean surgery’ protocol following surgical debridement is essential in diminishing risk of recontamination and infection. Hence, this must be the gold standard and should be clearly documented in operation notes. The extent of availability of a joint Orthoplastic theatre list provides a key limiting step in definitive bony fixation and soft tissue coverage of open tibia fractures.

594 Optimising Hand Trauma Care at a Major Trauma Centre (MTC) During the COVID-19 Pandemic

Introduction

This study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model.

Method

285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC).

Results

277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed.

Conclusions

The one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.

593 The Utility of Routine Operative Swab Culture in Uncomplicated Peri-Anal Abscesses

Introduction

Despite perianal abscess being a common presentation, certain aspects of its management remain controversial, especially the routine use of intra-operative swab cultures.

Method

A retrospective review of patients that underwent incision and drainage procedures for a perianal abscess over a six-month period was undertaken.

Results

Over 6 months, 50 patients were identified. The male to female ratio was 3:1 and median ASA score was 1. Only 6/50 patients presented with recurrent abscess and 1 patient had history of inflammatory bowel disease. On the basis of operative findings, 39 patients (78%) had uncomplicated abscess (not associated with cellulitis, sinus or fistula); swab cultures were performed in 26 (67%) of these patients. All patients were discharged on the same day; microbiology reports did not impact the treatment and no patients were followed up in clinic post-operatively or presented with recurrence. The number of unnecessary microbiology swabs undertaken in this cohort equates to approximately 52 unnecessary swabs a year. The cost of one swab is £10.10p, which means £520 could potentially be saved annually.

Conclusions

Routine intra-operative swab cultures do not impact management decisions, add to unnecessary costs and therefore should not be undertaken in uncomplicated or first presentation of peri-anal abscesses.

Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes

BACKGROUND

Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence-based optimal timings for radiotherapy and BRR to guide contemporary management.

METHODS

The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I respectively.

RESULTS

Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow-up of 27·1 (range 12·0-54·0) months for those having PMRT, 16·8 (1·0-50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0-48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies.

CONCLUSION

Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Effect of a national focused course on academic medicine for UK candidates applying for a Clinical Academic Programme

Background Academic medicine is crucial for healthcare advancement. However, recruitment of junior doctors into academia remains an area of concern globally. In the UK, a national integrated clinical academic pathway was developed to address these issues, with the Academic Foundation Programme as the 'first opportunity for research'. We aimed to evaluate whether a focused course on academic medicine could enhance knowledge, confidence and preparedness of candidates wishing to apply for an academic programme. Methods UK medical students attended a national course conducted by current UK Academic Foundation Programme doctors that comprised lectures on academic medicine and various aspects of the Academic Foundation Programme. An online questionnaire-based cross-sectional study was conducted with participants rating measures including knowledge, preparedness and confidence related to Academic Foundation Programme applications. Outcomes were measured using Likert scales (1=low; 5=high). Results In total, 103 out of 155 attendees from 11 different UK medical schools responded to the survey (66% response rate). Pre and post-course data showed increase in participants' knowledge (median score 2 vs 4, p < 0.0001), understanding of the application process (median score 2 vs 4, p < 0.0001), confidence (median score 2 vs 4, p < 0.0001) and preparedness (median score 2 vs 4, p < 0.0001) in applying for the Academic Foundation Programme. Conclusion To our knowledge this is the first study in the available literature that demonstrates a focused course on academic medicine may enhance UK medical students' knowledge, confidence and preparedness in applying for a clinical academic programme. Further research will ascertain whether such courses can augment trainee numbers undertaking and remaining within academic medicine.

Patellofemoral joint is an under reported joint in MRI knee - A retrospective, cross-sectional study

Background

Patellofemoral joint (PFJ) pathology accounts for upto 40% of cases of knee pain. It has been suggested that PFJ pathology may be underreported in Magnetic Resonance Imaging (MRI) Knee reports. The objective of this study was to elucidate whether PFJ was reported in MRI knee reports at our institution.

Materials and methods

A retrospective review of 103 consecutive Knee MRIs over a 2-month period was performed by an author, blinded to the reports, at our institution. We analysed whether PFJ was mentioned in MRI knee reports and whether any significant PFJ pathology was present in the scans of this cohort. Images were also reviewed for any underlying causes of PFJ pathology such as trochlear dysplasia (TD) that can result in patellar instability or maltracking.

Results

PFJ was not mentioned in 79/103 cases (77%). 24 cases had trochlear dysplasia. There was no association between PFJ reporting and trochlear dysplasia (p value = 0.50).

Conclusion

PFJ is not mentioned in the majority of Knee MRI reports. PFJ pathology is an important cause of anterior knee and should be reported.

•

The Patellofemoral joint was not mentioned in 77% of the MRI Knee reports.

•

A third of the cases had trochlear dysplasia.

•

PFJ pathology is a significant cause of anterior knee pain.

•

PFJ should be mentioned when reporting a MRI of knee.

Cognitive Aids in Medicine Assessment Tool (CMAT): preliminary validation of a novel tool for the assessment of emergency cognitive aids

Applying human factors principles to the design of clinical emergency guidelines is important. The UK Civil Aviation Authority uses a Checklist Assessment Tool for evaluating the content and usability of emergency drills before introduction into service on aircraft. We hypothesised that this model could be used to develop a generic medical tool. A three-stage modified Delphi process was used to adapt the above tool for use in designing medical emergency guidelines. The resulting Cognitive aids in Medicine Assessment Tool was then used to score and rank seven published difficult airway guidelines; the scores were used to assess its validity and reliability. Pearson's rank coefficient between these scores and scores from independent assessors was 0.89 (p = 0.007). Internal consistency, as assessed by Cronbach's alpha, was 0.74, 0.96 and 0.72 for the tool's three constituent domains of physical characteristics, content and layout/format, respectively. Inter-rater reliability, as assessed by Cohen's kappa, ranged from 0.33 to 0.72. The adoption of our tool has the potential to improve the usability of medical emergency guidelines.

Management and prognostic significance of pathological fractures through chondrosarcoma of the femur

PURPOSE

The aim of the study was to report overall survival, local recurrence and development of metastasis in a group of patients with femur chondrosarcoma that presented with or without a pathological fracture.

METHODS

A retrospective review was performed, and 182 patients (39 pathological fractures) that had been treated by oncologic surgery for femoral chondrosarcoma were included. The mean age of the series was 50 years (range, eight to 90) and 114 patients were male (63%). Mean follow-up was 113 months (range, three to 216). Cancer-specific overall survival, development of metastasis and local recurrence were analysed, grouping patients by grade (grade I / grade 2-3 / dedifferentiated).

RESULTS

Disease-specific survival in the entire group of chondrosarcoma of the femur was 69% (CI95% 63-76) at 5 years. Five-year disease-specific survival in the fracture group was 49% lower than in the control group 75% (p = 0.0001). Survival of patients with grade 1 chondrosarcoma with fracture was significantly less than those without fracture (p = 0.02) but there was no difference in those with grade 2-3 (p = 0.49) and dedifferentiated tumours (p = 0.09). The local recurrence rate of the entire series was 27%. Only dedifferentiated chondrosarcomas with an associated pathological fracture had a significantly higher rate of local recurrence. There was no relationship between development of metastases and fracture.

CONCLUSION

A pathological fracture of the femur has a negative prognostic influence in grade 1 chondrosarcoma and increases the risk of local recurrence in dedifferentiated femur chondrosarcomas.

The reporting quality of parallel randomised controlled trials in ophthalmic surgery in 2011: a systematic review

PURPOSE

Randomised controlled trials (RCTs) represent a gold standard for evaluating therapeutic interventions. However, poor reporting clarity can prevent readers from assessing potential bias that can arise from a lack of methodological rigour. The Consolidated Standards of Reporting Trials statement for non-pharmacological interventions 2008 (CONSORT NPT) was developed to aid reporting. RCTs in ophthalmic surgery pose particular challenges in study design and implementation. We aim to provide the first assessment of the compliance of RCTs in ophthalmic surgery to the CONSORT NPT statement.

METHOD

In August 2012, the Medline database was searched for RCTs in ophthalmic surgery reported between 1 January 2011 and 31 December 2011. Results were searched by two authors and relevant papers selected. Papers were scored against the 23-item CONSORT NPT checklist and compared against surrogate markers of paper quality. The CONSORT score was also compared between different RCT designs.

RESULTS

In all, 186 papers were retrieved. Sixty-five RCTs, involving 5803 patients, met the inclusion criteria. The mean CONSORT score was 8.9 out of 23 (39%, range 3.0-14.7, SD 2.49). The least reported items related to the title and abstract (1.6%), reporting intervention adherence (3.1%), and interpretation of results (4.7%). No significant correlation was found between CONSORT score and journal impact factor (R=0.14, P=0.29), number of authors (R=0.01, P=0.93), or whether the RCT used paired-eye, one-eye, or two-eye designs in their randomisation (P=0.97).

CONCLUSIONS

The reporting of RCTs in ophthalmic surgery is suboptimal. Further work is needed by trial groups, funding agencies, authors, and journals to improve reporting clarity.

Emergence of VIM-2 metallo-beta-lactamase producing Ralstonia pickettii clinical isolate in India

A multidrug-resistant clinical isolate of Ralstonia pickettii from a woman was analysed. Modified Hodge test was positive for carbapenemase production. Conjugation experiment revealed the presence of conjugative plasmid of >140 Kb size typed as IncN type. This is the first report of emergence blaVIM-2 in R. pickettii in India.

In vivo genotoxicity evaluation of a plant based antiarthritic and anticancer therapeutic agent Boswelic acids in rodents

The genotoxic potential of anti-inflammatory/anti-arthritic and anticancer plant based drug molecule Boswelic acids (BA) was studied by in vivo system. Systematic literature survey revealed that studies on the genotoxicity of BA are not available. Although reports on genotoxicity of Boswellia serrata dry extract and modified 3-O-acetyl-11-keto-beta-boswelic acid are available and these studies were conducted in in vitro systems. The earlier general toxicity study of BA has been conducted by us, revealed it to be non toxic. The genotoxicity was carried out in Wistar rats using different cytogenetic assay system-abnormalities viz. chromosomal aberrations; sperm morphology, micronuclei and comet assays. Six groups of animals, each comprised of five rats, were taken for each study. Group1-4 received BA at 125, 250, 500 and 1000 mg/kg p.o., respectively prepared as 2% gum acacia suspension, fifth group received a positive control cyclophosphamide (CP) 40 mg/kg p.o. or metronedazole (MTZ) 130 mg/kg p.o. or mercuric chloride (HgCl(2)) 0.864 mg/kg p.o. (as per the experiment requirement) whereas the sixth group kept as vehicle control. The results on the bases of the data obtained revealed that BA is quite safe as it did not show any genotoxicity at any dose level up to 1000 mg/kg. The positive controls used in different experiments showed highly significant abnormal cytogenetic changes in comparison to the control group.

Boswellic acids: A leukotriene inhibitor also effective through topical application in inflammatory disorders

Boswellic acids (BA), a natural mixture isolated from oleo gum resin of Boswellia serrata comprised of four major pentacyclic triterpene acids: beta-boswellic acid (the most abundant), 3-acteyl-beta-boswellic acid, 11-keto-beta-boswellic acid, and 3-acetyl-11-keto-beta-boswellic acid, is reported to be effective as anti-inflammatory, immunomodulatory, anti-tumor, anti-asthmatic and in Chron's disease. It inhibits pro-inflammatory mediators in the body, specifically leukotrienes via inhibition of 5-lipoxygenase, the key enzyme of leukotriene synthesis, is the scientifically proved mechanism for its anti-inflammatory/anti-arthritic activity. All previous work on BA for its biological activity has been done through the systemic application but no pre-clinical data reported for its anti-inflammatory activity by topical application. We here by report anti-inflammatory activity of BA through this route by applying different acute and chronic models of inflammation i.e., arachidonic acid and croton oil-induced mouse ear edema, carrageenan-induced rats paw edema and adjuvant-induced developing arthritis in rats. The results of the study revealed that the effect observed through this route is in accordance to the study conducted with the systemic route, thus establishing that BA when used through topical application is as effective as through the systemic route.

The gastric ulcer protective effect of boswellic acids, a leukotriene inhibitor from Boswellia serrata, in rats

Aim of the study is to evaluate the anti-ulcer efficacy of the boswellic acids (BA), a triterpenoid known as anti-inflammatory/anti-arthritic agent, which is in clinical use. The reason for the study is that, the known non-steroidal anti-inflammatory drugs (NSAIDs) are full of side effects especially ulceration which is at the top. BA, although, used as an anti-arthritic agent yet it is not only devoid of ulcer production but protective also. The activity evaluation was done by the following universally accepted animal models viz., pyloric ligation, ethanol-HCl, acetylsalicylic acid, indomethacin and cold restrained stress-induced ulceration in rats. Results of the present study revealed that BA possess a dose dependent antiulcer effect against different experimental models. It showed different degree of inhibition of the ulcer score towards different ulcerogenic agents. The ulcer score against various ulcer inducing agents viz., pyloric ligation, ethanol/HCl, (acute and chronic) acetylsalicylic acid, indomethacin and cold restraint stress, was inhibited by 39%, 38%, 51%, 31%, 37% and 42% respectively at 250mg/kg. From the data it is concluded that BA inhibited ulcer production non-specifically in all the experimental models, whereby, it is not possible to propose a single specific mechanism. Nevertheless it is possible that BA might be acting by increasing the gastric mucosal resistance and local synthesis of cytoprotective prostaglandins and inhibiting the leukotriene synthesis.

Immunomodulatory activity of an extract of the novel fungal endophyte Entrophospora infrequens isolated from Nothapodytes foetida (Wight) Sleumer

A novel camptothecin-producing endophytic fungus viz., Entrophospora infrequens was isolated from an important Indian medicinal plant Nothapodytes foetida. The present study reports evaluation ofbioactivities of two novel extracts viz., chloroform (CEEI) and methanolic (MEEI) extracts of Entrophospora infrequens with respect to their immunomodulatory potential in vitro and in vivo (in Balb/c mice). The endophyte E. infrequens was found to synthesize camptothecin, which tested positive in CEEI. The immunomodulatory potential of CEEI and MEEI was compared with standard camptothecin (CPT). Doses of the chloroform extract (CEEI) ranging from 12.5-100 mg/kg body weight, significantly (p < 0.05) stimulated the humoral and cell-mediated immune responses in a dose-dependent manner. MEEI on the other hand significantly (p < 0.05) stimulated the delayed type hypersensitivity (DTH) reaction (by nearly 80%), plaque forming cell (PFC) assay (33%), phagocytic response (38%) and haemagglutination antibody (HA) titre [IgM by 79.07% and IgG by 62.05%] at a dose of 12.5 mg/kg body weight. The present study is the first report of the immunomodulatory potential of this neoteric camptothecin-producing endophyte from Nothapodytes foetida.

Inhibition of early and late phase allergic reactions by Euphorbia hirta L

A 95% ethanol extract from whole aerial parts of Euphorbia hirta (EH A001) showed antihistaminic, antiinflammatory and immunosuppressive properties in various animal models. EH A001 inhibited rat peritoneal mast cell degranulation triggered by compound 48/80. It significantly inhibited dextran-induced rat paw edema. EH A001 prevented eosinophil accumulation and eosinophil peroxidase activity and reduced the protein content in bronchoalveolar lavage fluid (BALF) in a 'mild' model of asthma. Moreover, the CD4/CD8 ratio in peripheral blood was suppressed. EH A001 attenuated the release of interleukin-4 (IL-4) and augmented interferon-gamma (IFN-gamma) in ovalbumin-sensitized mouse splenocytes. The results were compared with the effects of known compounds, ketotifen, cetirizine and cyclophosphamide. These findings demonstrated that Euphorbia hirta possessed significant activity to prevent early and late phase allergic reactions.

Isolation, characterization and biological evaluation of datura lactones as potential immunomodulators

Phytochemical investigation of Datura quercifolia (Solanaceae) plant yielded a new datura lactone, 1beta,5alpha,12alpha-trihydroxy-6alpha,7alpha,24alpha,25alpha-diepoxy-20S,22R with-2-enolide (1), along with two known compounds, 2 and 3. The structure of 1 was established on the basis of spectral analysis, as well as by its chemical transformation into known datura lactones. These compounds have been evaluated for immunomodulatory activity by observing their effect on antibody production, T-cell and B-cell activation, and cytokine production from splenocytes. Compound 2 was found to be the most promising immunostimulator in the present study.

Adaptogenic activity of glyco-peptido-lipid fraction from the alcoholic extract of Trichopus zeylanicus Gaerten (part II)

Anti-stress activity was carried out on glyco-peptido-lipid (AF) fraction from the alcoholic extract of Trichopus zeylanicus Gaerten and demonstrated against a battery of tests in rats and mice. AF exhibited significant anti-stress activity in dose-related manners in all the parameters studied against different models used to induce non-specific stress viz physical and chemically. The major parameters studied were immobilization induced gastric ulceration, adjuvant-induced trauma (Stress); humoral antibody synthesis in normal and immuno-suppressed mice and delayed type of hypersensitivity (DTH) reaction, chemically stress-induced alteration in hepatic function and anti-oxidant activity. The extract of Withania somnifera root (a commercial preparation available locally, Dabur India ltd.) was used to compare the results. In the safety evaluation study the maximum tolerance dose (MTD) and oral LD50 were found to be more than 3000 mg/kg, with no signs of abnormalities or any mortality observed for 15 days period under observation after single dose of drug administration. Feeding behaviour and fecal output were normal.

Osmolality revisited—Deriving and validating the best formula for calculated osmolality

OBJECTIVE

To derive a formula that can be used (i) to calculate osmolality in normal patients as well as those that are hyperglycemic and intoxicated, and (ii) to predict the presence of unexplained compounds with the osmol gap calculation in the presence and absence of ethanol. DESIGN AND EXPERIMENTS: We performed in vitro experiments to determine the relationship of serum osmolality with sodium, potassium, urea, glucose, ethanol, methanol, and ethylene glycol. Several formulas were then tested for their validity in predicting osmolality in normal individuals. Finally, we assessed whether these formulas would allow us to calculate the osmolality gap (OG) that may be indicative of the presence of other osmotically active compounds. The OG calculation was done both in the presence and absence of ethanol. In this way, the OG should be able to detect compounds like methanol and ethylene glycol even in the presence of ethanol which is easily measured and is very often present in the above-named poisonings.

RESULTS

Experimental results show that glucose, ethanol, methanol, and ethylene glycol need factors of 1.15, 1.20, 1.07, and 1.00, respectively, to accurately predict osmolality. The factors for glucose and ethanol were then validated in normal subjects as well as in a large patient database. The formulas below predicted osmolality very well in patients whether ethanol was present or not. All concentrations are expressed in mmol/L. The mean osmol gap for healthy subjects without ethanol present was 0.77 +/- 3.80 mosM/kg with the reference interval being -6.68 to 8.23 mosM/kg for formula 1 and -8.04 to 6.50 mosM/kg for formula 2. The mean osmol gap (OG) in patients who had ethanol present was 1.22 +/- 5.32 for formula 1 and -0.2 +/- 5.0 for formula 2.

CONCLUSIONS

This study shows that factors of 1.20 and 1.15 have to be applied to ethanol and glucose to allow for accurate calculation of osmolality and osmolality gap. There were insufficient patient data to verify the factors for methanol and ethylene glycol.

Piperine modulates permeability characteristics of intestine by inducing alterations in membrane dynamics: influence on brush border membrane fluidity, ultrastructure and enzyme kinetics

Piperine (1-Piperoyl piperidine) is a major alkaloid of Piper nigrum Linn. and Piper longum Linn. It is shown to possess bioavailability-enhancing activity with various structurally and therapeutically diverse drugs. The mechanism of enhancing the bioavailability, is, however, not understood. We hypothesize that piperine's bioavailability-enhancing property may be attributed to increased absorption, which may be due to alteration in membrane lipid dynamics and change in the conformation of enzymes in the intestine. Results of membrane fluidity studies using an apolar fluorescent probe, pyrene (which measures the fluid properties of hydrocarbon core), showed an increase in intestinal brush border membrane (BBM) fluidity. Piperine also stimulated Leucine amino peptidase and Glycyl-glycine dipeptidase activity, due to the alteration in enzyme kinetics. This suggests that piperine could modulate the membrane dynamics due to its apolar nature by interacting with surrounding lipids and hydrophobic portions in the protein vicinity, which may decrease the tendency of membrane lipids to act as stearic constrains to enzyme proteins and thus modify enzyme conformation. Ultra structural studies with piperine showed an increase in microvilli length with a prominent increase in free ribosomes and ribosomes on the endoplasmic reticulum in enterocytes, suggesting that synthesis or turnover of cytoskeletal components or membrane proteins may be involved in the observed effect. In conclusion, it is suggested that piperine may be inducing alterations in membrane dynamics and permeation characteristics, along with induction in the synthesis of proteins associated with cytoskeletal function, resulting in an increase in the small intestine absorptive surface, thus assisting efficient permeation through the epithelial barrier.

Pathogenesis of Hyperhomocysteinemia-New Insights

Mild to moderately elevated levels of homocysteine (Hey) in plasma, denoted as hyperhomocysteinemia, is emerging as a prevalent and strong risk factor for atherosclerotic vascular disease in coronary, cerebral and peripheral vessels, as well as for arterial and venous thromboembolism. Despite its clinical significance, the molecular mechanism of homocysteine's effects is not yet clearly defined. Most of the effects of homocysteine that have been demonstrated in vitro, affecting endothelial function have been attributed to the oxidant reactivity of this molecule, which is shown to affect the vasoregulatory and thrombotic/fibrinolytic function of endothelium. However, the relevance of these observations to the clinical situations is questionable, since excessively high concentrations of homocysteine are used in most of the experiments. We have observed that homocysteine, at physiologically relevant concentrations, specifically induces the expression of tissue factor by monocytes, and a non-specific redox effect is not involved. Tissue factor expression by monocytes is mediated by increased intracellular concentrations of the metabolic intermediate, S-adenosylhomocysteine, which is a potent inhibitor of methyl transferases. These studies suggest that tissue factor expression by circulating monocytes by intracellular perturbations may be a plausible mechanism by which homocysteine may induce thrombosis.

Induction of monocyte tissue factor expression by homocysteine: a possible mechanism for thrombosis

Moderately elevated plasma homocysteine levels are an important independent risk factor for arterial and venous thrombosis and for atherosclerosis. Some investigators have proposed that homocysteine's effects result from oxidant injury to the vascular endothelium or from an alteration in endothelial function. However, homocysteine may have other cellular targets. We now report that homocysteine, at physiologically relevant concentrations, induces the expression of tissue factor by monocytes. In response to homocysteine, monocytes express procoagulant activity in a dose-dependent and a time-dependent manner. This activity is attributable to tissue factor because it was dependent on factor VII and blocked by anti-tissue factor antibodies. Tissue factor mRNA levels were also increased in monocytes after homocysteine treatment. The effect was found to be specific because analogues of homocysteine (homocystine and homocysteine thiolactone) did not mimic homocysteine's activity, nor did other thiol compounds (cysteine, 2-mercaptoethanol, dithiothreitol). On the other hand, methionine, the metabolic precursor of homocysteine, was active though less potent than homocysteine. Catalase and superoxide dismutase (scavengers of H(2)O(2) and O(2)(-) Radicals, respectively) were unable to block the expression of tissue factor induced by homocysteine, as was a 5-fold excess of the reducing agent 2-mercaptoethanol. We conclude that the induction of tissue factor expression by circulating monocytes is a plausible mechanism by which homocysteine may induce thrombosis and that a nonspecific redox process is not involved.

Piperine mediated alterations in lipid peroxidation and cellular thiol status of rat intestinal mucosa and epithelial cells

Piperine (1-Piperoyl piperidine) is the major alkaloid of black and long peppers used widely in various systems of traditional medicine. The present study investigates the toxicity of piperine via free-radical generation by determining the degree of lipid peroxidation and cellular thiol status in the rat intestine. Lipid peroxidation content, measured as thiobarbituric reactive substances (TBARS), was increased with piperine treatment although conjugate diene levels were not altered. A significant increase in glutathione levels was observed, whereas protein thiols and glutathione reductase activity were not altered. The study suggests that increased TBARS levels may not be a relevant index of cytotoxicity, since thiol redox was not altered, but increased synthesis transport of intracellular GSH pool may play an important role in cell hemostasis and requires further study.

Piperine modulation of carcinogen induced oxidative stress in intestinal mucosa

Reactive oxygen species (ROS) and reactive metabolic intermediates generated from various chemical carcinogens are known to play an important role in cell damage and in the initiation and progression of carcinogenesis. Many radical scavengers, interestingly naturally occuring antioxidants have been found to be effective in inhibiting the induction of carcinogenesis by a wide variety of chemical carcinogens. Studies have also indicated that various spice principles form an important group as antioxidants. In the present study our goal was to investigate whether piperine an pungent principle of black and long peppers was able to inhibit or reduce the oxidative changes induced by chemical carcinogens in rat intestinal model. Carcinogenesis was initiated in intestinal lumen of male rats with 7,12,dimethyl benzanthracene, dimethyl amino-methyl azobenzene and 3-methyl cholenthrene. Oxidative alterations were assessed by determining thiobarbituric reactive substances, mainly malonaldehyde (as a measure of lipid peroxidation), thiol status and expression of gamma-GT and Na+-K+-ATPase activity in intestinal mucosa. Data indicated that carcinogens treatment induced GSH depletion with substantial increase in thiobarbituric reactive substances and enzyme activities. Piperine treatment with carcinogens resulted in inhibition of thiobarbituric reactive substances. It mediated a significant increase in the GSH levels and restoration in gamma-GT and Na+-K+-ATPase activity. The studies thus indicate a protective role of piperine against the oxidative alterations by carcinogens. It may be suggested that piperine modulates the oxidative changes by inhibiting lipid peroxidation and mediating enhanced synthesis or transport of GSH thereby replenishing thiol redox.

Permeability characteristics of piperine on oral absorption--an active alkaloid from peppers and a bioavailability enhancer

Piperine, [1-[5-[1,3-benzodioxol-5-yl]-1-oxo-2,4, pentadienyl] piperidine], is a pungent alkaloid present in Piper nigrum Linn, and P. longum Linn. It is shown to enhance the bioavailability of various structurally and therapeutically diverse drugs. A concise mechanism responsible for its bioavailability enhancing action is poorly understood. This study is an effort to understand the absorption dynamics of piperine in intestine on oral absorption. It encompasses intestinal everted sacs as an experimental model. Cycloheximide treatment and exclusion of Na+ salts from incubating medium were the variables used. Absorption half life, absorption rate, absorption clearance and apparent permeability co-efficient were computed from the data. Experiments to denote physico-chemical characteristics of this moiety exhibited that it is a weak base, highly lipophilic in nature with partial solubility in aqueous media. It exhibited passive diffusion constituting non-saturable absorption kinetics. Transport of piperine was not resisted by UWL and was proposed to be absorbed through transcellular pathway. It displayed short absorption clearance and high apparent permeability co-efficient. Data thus obtained suggested that piperine is absorbed very fast across the intestinal barrier. It may act as an apolar molecule and form apolar complex with drugs and solutes. It may modulate membrane dynamics due to its easy partitioning thus helping in efficient permeability across the barriers.

Fine needle aspiration cytology of a subcutaneous metastasis of a malignant Brenner tumor of the ovary. A case report

The fine needle aspiration cytologic findings of a subcutaneous metastasis from a malignant Brenner tumor of the ovary are described. Polygonal cells in clusters and single cells with fine cytoplasmic elongations, moderately pleomorphic nuclei having granular chromatin and multinucleate cells, occasional but prominent grooving of nuclei and many mitotic figures were the salient cytologic features. The cytohistologic correlation was good. The rare metastatic site of this unusual ovarian neoplasm makes this an interesting case and the first of its kind to the best of our knowledge.

Fine needle aspiration biopsy in gynecologic malignancies. Recurrent and metastatic lesions

This study evaluated the efficacy of fine needle aspiration biopsy (FNAB) in 80 suspected cases of recurrent and metastatic gynecologic malignancies. RNAB was performed at 90 sites in 80 patients; 42 of the sites were deep seated. The cytologic diagnosis correlated well with either histology (7 cases) or clinical follow-up. FNAB diagnosis of deep-seated lesions precluded exploratory laparotomy, and further therapy was administered accordingly. Thus, FNAB in gynecologic malignancies was safe, reliable and cost effective.

Cutaneous sarcoidosis masquerading as relapsed borderline tuberculoid leprosy?

A patient with cutaneous sarcoidosis is presented. The patient was diagnosed initially as borderline tuberculoid leprosy downgrading to borderline lepromatous leprosy and received a full 2 years of World Health Organization multibacillary drug treatment (MDT). Bilateral hilar lymphadenopathy on chest X-ray and cutaneous anergy manifested by negative Mantoux, candidin and trichophytin skin tests suggested the diagnosis of sarcoidosis. Histopathology confirmed this diagnosis. The subcutaneous nodule seen in this patient is a rare type of cutaneous sarcoidosis.

Aspiration cytology of Wilms' tumor

We reviewed the cytomorphologic features of fine needle aspiration biopsy (FNAB) smears from 15 cases of renal, extrarenal and metastatic Wilms' tumor. The findings were correlated with the histopathologic features. In cytology smears, blastemal cells were recognized in all cases. The following cell types were seen: epithelial cells, 60%; stromal component, 33.3%; tubular differentiation, 26.6%; and glomeruloid differentiation, 33.3%. FNAB smears of the metastatic lesions in the liver and of the primary lesions did not reveal any significant difference in cellular composition. Subcutaneous soft tissue metastasis from an anaplastic Wilms' tumor showed marked anaplasia and pleomorphism of blastemal cells along with frequent mitosis and bizarre tumor giant cells. Extrarenal Wilms' tumor showed only blastemal cells, though histopathology showed the classic triphasic pattern along with skeletal muscle differentiation. There were no complications attributable to the procedure. Recognition of these cellular components in FNAB smears will help in establishing an FNAB diagnosis of Wilms' tumor, particularly when preoperative chemotherapy is needed.

Immunopharmacological properties of azepino [2, 1-b] quinazolin-12(6H)-one-7, 8, 9, 10-tetrahydro (RLX)

The effect of azepino [2,1-b]quinazolin-12(6H)-one-7, 8, 9, 10-tetrahydro (RLX) was studied on cell-mediated and humoral components of the immune system. In single (50, 100 and 200 mg/kg) and multiple (6.25, 12.50, 25 and 50 m/kg) oral dose schedules RLX significantly reduced the early (4 h) and delayed (24 and 48 h) hypersensitivity reactions to SRBC in mice. Daily oral administration of RLX (25, 50 and 100 mg/kg) produced a dose-related reduction in developing adjuvant arthritis in rats. In carrageenan-induced pleurisy in rats RLX (25, 50 and 100 mg/kg p.o.) caused a marked reduction in the volume of pleural exudate (25.26-59.64%) and infiltration of leucocytes (28.75-50.29%) into the pleural cavity. RLX produced marked inhibition of humoral antibody synthesis both in mice and rats and that of complement fixing antibody in mice. It was not cytotoxic and showed no appreciable effect on the responsiveness of splenocytes to mitogens. The observed effect of RLX on cell-mediated and humoral immune responses does not appear to be the result of general toxicity.

Primary extrarenal Wilms' tumour: identification of a putative precursor lesion

We report a case of primary extrarenal Wilms' tumour which, on histological examination, revealed a zone of hyalinized blastema adjacent to, and within the tumour capsule. The tumour showed a predominant stromal component. The presence of the hyalinized blastema adjacent to the tumour raises the possibility that some cases of extrarenal Wilms' tumour may have a precursor lesion.

Piperine-mediated changes in the permeability of rat intestinal epithelial cells. The status of gamma-glutamyl transpeptidase activity, uptake of amino acids and lipid peroxidation

The effect of piperine (1-[5-(1,3-benzodioxol-5-yl)-1-oxo-2,4-pentadienyl]piperidin e), (from Piper nigrum) on the absorptive function of the intestine was studied. In vitro experiments showed that piperine (25-100 microM) significantly stimulated gamma-glutamyl transpeptidase (gamma-GT, EC 2.3.2.2.) activity, enhanced the uptake of radiolabelled L-leucine, L-isoleucine and L-valine, and increased lipid peroxidation in freshly isolated epithelial cells of rat jejunum. The kinetic behaviour of gamma-GT towards substrate and acceptor altered in the presence of piperine. In the presence of benzyl alcohol, an enhanced gamma-GT activity due to piperine was maintained. These results suggested that piperine may interact with the lipid environment to produce effects which lead to increased permeability of the intestinal cells.

Effect of salai guggal ex-Boswellia serrata on cellular and humoral immune responses and leucocyte migration

Effect of alcoholic extract of salai guggal (AESG) was studied on cellular and humoral immune responses in mice and leucocyte migration in rats. Oral administration of AESG strongly inhibited the antibody production and cellular responses to sheep red blood cells in mice. It inhibited the infiltration of polymorphonuclear leucocytes and reduced the volume of pleural exudate in carrageenan induced pleurisy in rats. It showed no cytotoxic effect.

Assessment of Healthcare Waste Generated by Government Hospital in Agra City, India

Health care wastes include anatomical, pathological and clinical infectious/ hazardous organic and inorganic waste. The waste is disposed off in unscientific manner. The study has been conducted in the government health care establishment only to reveal the per day waste generation on each patient, present mode of waste management within the units bed, our suggestions which have helped the units to improve their waste management practices, in the city of Agra. Keywords: Waste management, Health scare waste, Management, Government hospitaldoi:10.3126/on.v5i1.794Our Nature (2007)5:25-30