Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients

INTRODUCTION

Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes.

METHODS

After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2.

RESULTS

1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population.

CONCLUSIONS

Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

Surgical Site Infections in Colorectal Resections: What is the Cost?

INTRODUCTION

Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives.

METHODS

Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC).

RESULTS

Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI.

CONCLUSIONS

SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.

Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use

INTRODUCTION

Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients.

METHODS

National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors.

RESULTS

One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs.

CONCLUSIONS

We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.

Impact of Race and Ethnicity on Perioperative Outcomes During Hysterectomy for Endometriosis

STUDY OBJECTIVE

To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals.

PATIENTS

Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis.

INTERVENTIONS

Compare perioperative complications based on patient race and ethnicity.

MEASUREMENTS AND MAIN RESULTS

A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) compared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45).

CONCLUSION

Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications.

Endoscopic stricturotomy with pulsed argon plasma and balloon dilation for refractory benign colorectal strictures: a case series

Benign strictures of the colon and rectum affect a sizable portion of patients who have an underlying inflammatory disease or who have undergone recent surgery. Etiologies include inflammatory bowel disease (IBD), post-surgical ischemia, anastomotic strictures, non-steroidal anti-inflammatory drugs (NSAIDs), and complicated diverticulitis. Refractory colorectal strictures are very difficult to manage and often require repeated and different treatment options. We report a novel technique using argon plasma coagulation (APC) with endoscopic balloon dilation (EBD) as a safe and effective treatment modality for refractory benign colorectal strictures. Four patients with symptomatic benign colorectal strictures were referred for endoscopic treatment. In all cases (two females and two males; average age 62 years), the endoscopic and radiographic assessment showed significant strictures (diameter, 4-13 mm). The stricture was secondary to Crohn's disease in one patient and anastomotic strictures in the other three patients. Endoscopic stricturotomy through fulguration and tissue destruction using argon plasma at 1.5 liters/minute, effect 2, and 40 watts was performed, followed by EBD. All patients were treated by one advanced endoscopist. The primary outcomes were the efficiency and safety of endoscopic stricturotomy with pulsed argon plasma and balloon dilation. The resolution of stricture was achieved in all patients. No complications were reported. We believe that combined APC with EBD is a safe and effective technique in the treatment of benign colonic stricture.

Age and Medicare Insurance are Barriers to Telemedicine Access—A Quality Improvement Project

Background

Telehealth use has had widespread expansion and adoption over the past two years. This study aims to evaluate access to telehealth essentials (TE) using a novel metric.

Methods

This single institute study surveyed outpatient surgical patients to determine their access to TE. Generalized linear mixed models were used to determine the relationship of demographic and county-level variables on access to four TE.

Results

138 patients were surveyed. Sixty-six (47.8%) were from Appalachian Kentucky. In the survey cohort, 122 (88.4%) had smart phones, 109 (80.7%) had devices with video messaging capabilities, 106 (80.9%) had cellular reception, and 112 (82.4%) had access to WiFi. Increasing age and Medicare insurance were the most consistent predictors of lack of access to TE.

Conclusion

Rural Appalachian Kentucky has access to TE. Telehealth has the potential to decrease the healthcare inequity in rural populations, but incompletely address this inequity for the aging population.

Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky

BACKGROUND

Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-d delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky.

METHODS

The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of the last colonoscopy and the first specialist visit were identified through the claims. Bivariate and logistic regression analysis was performed to identify factors associated with delay to CRC specialist visit.

RESULTS

A total of 3927 patients from 100 hospitals in Kentucky were included. Approximately, 19% of patients with CRC visited a specialist more than 14 d after CRC detection on colonoscopy. Delay to specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, P < 0.0001), low and moderate education level (OR 1.4 and 1.3, respectively, P = 0.0127), and stage I CRC (OR 1.5, P < 0.0001). There was a higher percentage of delay to specialist among Medicaid patients (44.0%) than Medicare (18.0%) and privately insured patients (18.8%).

CONCLUSIONS

We identified Medicaid insurance, low education attainment, and early stage CRC diagnosis as independent risk factors associated with 14-d delay in seeking specialist care after CRC detection on colonoscopy.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure (P = 0.037) and a higher wound class (P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure (P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI (P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure ( P = 0.037) and a higher wound class ( P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure ( P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI ( P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery

BACKGROUND

Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS).

DESIGN

Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012-December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales.

RESULTS

The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group.

CONCLUSIONS

TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest

BACKGROUND

Open reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients.

METHODS

Albany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years.

RESULTS

Eighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group.

CONCLUSIONS

In this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.

Predictors of Hospital Readmission after Bariatric Surgery

BACKGROUND

Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission.

STUDY DESIGN

Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors.

RESULTS

There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%.

CONCLUSIONS

Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

Extended spectrum beta lactamase peritonitis: Time for innovation?

Extended spectrum beta lactamase (ESBL) producing bacteria that are capable of hydrolyzing even third generation cephalosporin are emerging as a potent threat. We report a seven-year-old child on continuous ambulatory peritoneal dialysis, who developed ESBL producing Klebsiella pneumoniae peritonitis. The bacterium was resistant to the usual intraperitoneal antibiotics. We successfully treated the child with intravenous meropenem along with oral cotrimoxazole. The case highlights the menace of ESBL peritonitis, as also a need for the development of guidelines for such a scenario, which is becoming increasingly common in India.

A study of obliquity of femoral shaft in Eastern Indian population

In the erect posture, femur is not absolute vertical, being separated above from its fellow by a considerable interval, which corresponds to the breadth of the pelvis, and inclines gradually medially and downward, so as to approach its fellow, for the purpose of bringing the knee joints near the line of gravity of the body. In the present study obliquity of femoral shaft measured in 127 dry femora. Mean obliquity of femoral shaft for 62 left sided femora found 8.431 degrees with standard deviation of 2.361 degrees whereas for 65 right sided femora were found to be 7.708 degrees with standard deviation of 2.425 degrees. When total 127 femora considered, mean bicondylar angle of 8.061 +/- 2.412 degrees was obtained. Though statistically insignificant, mean bicondylar angle determined on left side was higher than that on the right side.

True palmar pattern in vitiligo--a case control study

Characteristic epidermal ridges formed on the finger pad and on the palm by the end of the second trimester and remain unchanged thereafter and those are responsible for the highly specific finger prints of each individual. These ridges are nither influenced by later prenatal period nor they subject to any influence in the postnatal environmental factors because the formation of ridge patterns gets already completed by about the eighteenth week of gestation. Dermatoglyphics is a scientific study of such epidermal ridges. Dermatoglyphic study of both palms of clinically diagnosed vitiligo patients and control subjects were carried out and statisticaltly analysed in respect to sex and side of hands. The study revealed variable number of deviations of this patterns in Vitiligo patients when compared with that of control. Increased number of true palmar patterns in right hypothenar, right thenar and both inter digital areas 2 (ID-2) and decreased TPP in Rt. ID3, Rt. ID4 in vitiligo male patients and increased TPP in Rt. Hypothenar and Rt. ID1 and decreased TPP in Rt. ID2 and Lt. ID 3 in vitiligo female patients while compared with that of the control group. Some of the variations observed were stastically significant.

Prevalence and causes of low birth weight in India

INTRODUCTION

The aims of the study are (i) to understand inter-zone and interstate variation of low birth weight (LBW) and (ii) to determine the key variables to reduce LBW in India.

METHODS

Using the latest National Family Health Survey (NFHS) data of 2005-06 which showed the percentage distribution of LBW infants, ANOVA and post-hoc test were performed to determine the spatial variation of birth weight. The covariates which influence LBW fell into three categories: (i) social variables which included location, mother's education, religion, access of mothers to newspapers, television and family structure; (ii) economic variable namely, the wealth index, and (iii) biological variables which consisted of sex of the children, birth order, and mother's body mass index (BMI). Three models of Logistic regression were carried out to examine the influence of the combinations of these direct and indirect factors.

RESULTS

In India, nearly 20% of new borns have LBW. Males have less frequency of LBW than females. The North-east zone has the lowest prevalence of LBW while the north zone has the highest. Mother's education, access to TV and nuclear family, and intake of iron tablets are the most important socio-economic influences on the determination of birth weight in India.

CONCLUSION

It is essential to provide proper diet and nutritional care of mothers during pregnancy. Increased education of mothers through programmes in TV and newspapers articles have significant roles to play in reducing LBW in India.

Prospective study of application of biological communication (cybernatics) in management of chronic low back pain--a preliminary report

To observe the effects of application of cybernetics (theories of communication). This is an open level prospective study, involving patients with chronic low back pain of more than 3 months. Assessment were done before the start of therapy and after the completion of therapy every day for consecutive 6 days of treatment protocol. A total of 8 patients were enrolled (4 male, 4 female). The Visual Analogue Scale (VAS) was used to assess pain, Oswestry Disability Scale (ODI) was applied for scoring disability. ODI was scored at the start of treatment on 1st day and at the end of the treatment on 6th day. Mean VAS reduced from 8.12 to 6.93 after 1st day, which was also statistically significant (p < .01) .This trend continued and there was very significant reduction (p < .001) of VAS in the end when means were compared with pretreatment value. Mean Oswestry disability index reduced from 49.875 to 18.44 at the end of treatment which was statistically very significant (p < 0.001). There were significant improvements in all the outcome measured after Scrambler therapy.

Long term effect of monosodium glutamate in liver of albino mice after neo-natal exposure

Mono Sodium Glutamate (MSG) is a naturally occurring excitatory neurotransmitter. It is extensively used as a food additive and flavoring agent for its UMAMI taste. Simultaneously it is being implicated for varied pathological condition like obesity, gonadal dysfunction, learning difficulty etc. It produces oxygen derived free radicals and metabolized in liver. Neonate mice are sensitive and suffer from adverse effects. Present work was undertaken to study the long term effects on histology of liver following MSG injection in neonates. The changes in the liver parenchyma of 75 days old mice showed variable changes. Areas around central vein were most affected. The liver cords were disrupted, dilated sinusoids, prominent Kupffer cells with accumulation of particulate matter.There were inflammatory cells around central vein. The hepatocyte cell membrane were disrupted, cytoplasm vacuolated, nucleus were pyknotic. Even the normal looking cells showed depletion of PAS +ve material in the cytoplasm.The long term effect on histology showed moderate and patchy hepatocellular damage.

Kinetic Studies of the Cyclization of Singlet Vinylchlorocarbenes

[reaction: see text] Vinylchlorocarbenes (R = Me or Cl) cyclize to cyclopropenes with k = (2.4-5.1) x 10(7) s(-1) or (3.1-4.5) x 10(6) s(-1), respectively, in solution at room temperature. The corresponding E(a) values are 6.6 and 5.7 kcal/mol. Excited diazirines are also likely precursors of the cyclopropenes.

Drainage and Coalescence in Standing Foams

A theoretical model is presented for the drainage, collapse, and coalescence in standing foams. The foam is assumed to consist of pentagonal dodecahedra and coalescence is assumed to occur due to a variation in the sizes of the films which constitute the faces of these polyhedra. Even in a monodispersed foam containing bubbles having the same volume, the film areas are not identical, but are distributed randomly about a mean. This leads to a nonuniformity of film-drainage rates and hence of film thicknesses within any volume element in the foam. Smaller films drain faster and rupture earlier, causing the bubbles containing them to coalesce. The evolution of coalescence is monitored via the mean bubble volume which varies in the vertical direction. The model is also able to predict the evolution of the surfactant concentration profile as it changes due to coalescence and collapse. Simulations are performed to examine the effect of various parameters, such as the apparent diffusion coefficient of the surfactant, the distribution of film sizes, and the concentrations of surfactant and salt in the foaming solution on the drainage and collapse behavior of the foam.

Interaction of cycloalkanoprogesterones with mammalian progesterone receptor: binding of pregna-D'-pentaranes in the calf uterine cytosol

Pregna-D'-pentaranes (pentaranes) are modified progesterones with demonstrable progestational activity and contraceptive effect. We have examined the steroid binding characteristics of the two newly synthesized progesterone analogs, Pentarane A (16 alpha, 17 alpha-cyclohexanoprogesterone) and Pentarane B (6 alpha-methyl, 16 alpha, 17 alpha-cyclohexanoprogesterone), and studied the nature of their interaction with progesterone receptor (PR) from the chicken oviduct and the calf uterine cytosols. Pregna-D'-pentaranes exhibited no affinity for the chick PR but interacted with the calf uterine PR as did R5020. The pentaranes, however, bound PR less tightly. R5020- or pentarane-bound PR sedimented as an 8S moiety in 8-30% linear glycerol gradients. Thermal transformation of receptor resulted in the reduction of the 8S form, and caused an increase in the binding of R5020- and progesterone-bound PR complexes to DNA-cellulose. The pentarane-bound PR bound poorly, if at all, to DNA-cellulose. Our data suggest that pentaranes exhibit both similarities and differences with natural and synthetic progestins with respect to their interaction with calf uterine PR. The lack of pentarane binding to chicken PR is reminiscent of the general phenomenon that antiprogestins (RU486, ZK98299, and Org 31710 and Org 31806) do not interact with chicken PR. Pentaranes, therefore, represent unique steroid analogs to investigate the molecular mechanism of steroid hormone action.

Phosphorylation of chicken oviduct progesterone receptor by cAMP-dependent protein kinase

Phosphorylation of immunopurified chicken oviduct progesterone receptor (PR) was studied in intact cells and under cell-free conditions. Cytosol PR was isolated by incubation with anti-PR monoclonal antibody alpha PR22 adsorbed to protein A-Sepharose and suspended in a reaction mixture containing 10 mM Mg2+, 0.1 mM [gamma-32P]ATP, and the catalytic subunit of cAMP-dependent protein kinase (cAMP-PK) from bovine heart. All three major proteins of avian PR (PR-A, 79 kDa; PR-B, 110 kDa; 90 kDa) incorporated 32P-radioactivity on serine residues. The phosphorylation reaction was inhibited by synthetic inhibitors of protein kinases, H-8 and 20-residue peptide IP20. A 40 degrees C preexposure of PR oligomer increased phosphorylation of the 90-kDa protein, known to be a heat-shock protein (hsp-90). The extent of the phosphorylation reaction was temperature-dependent as the 32P-incorporation into PR-A and PR-B increased gradually, showing a maximum at 37 degrees C. Multiple phosphopeptides (4-7) were resolved by two-dimensional electrophoresis chromatography following cleavage of 32P-labeled peptides with trypsin. Both A and B forms of receptor showed similar phosphorylation patterns with B receptor digestion exhibiting two to three additional peptides. Under physiological conditions, preincubation of oviduct mince with forskolin, a regulator of intracellular cAMP levels, caused a greater extent of phosphorylation of PR-A and PR-B proteins. The results of this study demonstrate that chicken oviduct PR is an excellent substrate for the action of cAMP-PK in vitro and that this enzyme may be a physiological regulator of progesterone action in the oviduct.

Novel antiprogestins Org 31806 and 31710: interaction with mammalian progesterone receptor and DNA binding of antisteroid receptor complexes

We have examined steroid binding parameters and transformation of calf uterine progesterone receptor (PR) liganded with progestins (progesterone and R5020) and the newly synthesized antiprogestins (Org 31806 and 31710). Species specificity analysis indicated that [3H]R5020 binding in the chicken oviduct cytosol could be eliminated in the presence of 100-fold excess radioinert progesterone and R5020 but not Org 31806 and 31710. In the calf uterine cytosol, the progestins and the antiprogestins appeared to interact with the same PR as revealed by the displacement of [3H]R5020 by all of the above steroids. When the extent of [3H]R5020 binding was examined in the presence of different concentrations of radioinert steroids, the relative affinity with which these compounds interacted with the uterine PR was found to be comparable. A 23 degrees C incubation of cytosol transformed the progestin-bound PR complexes increasing their binding to DNA-cellulose from 5 (0 degrees C, nontransformed) to 35%. Under these conditions, 20% Org 31710- and RU486-occupied PR complexes bound to DNA-cellulose whereas only 10% Org 31806-receptor complexes were retained by the resin. Transformation (23 degrees C) of cytosol receptor caused a loss of the larger 8 S form and an increase in the smaller 4 S form. In its unliganded state or when it was complexed with R5020 or the antiprogestins, incubation of PR at 23 degrees C led to dissociation of the receptor-associated 90 kDa heat-shock protein (hsp90). The PR-hsp90 association was stabilized in the presence of 10 mM iodoacetamide when the ligand binding site was occupied by Org 31806 and 31710. The R5020-receptor complexes, however, allowed release of hsp90 under the above transforming conditions. Our results indicate that although Org 31806 and 31710 show no affinity for the avian PR, these steroids interact with the mammalian PR. We propose that the reported antiprogestational effects of Org 31806 and 31710 are mediated via their interaction with PR which appears similar to one that exists between PR and RU486.

ZK98299--a new antiprogesterone: biochemical characterization of steroid binding parameters in the calf uterine cytosol

We have examined steroid binding characteristics of a newly synthesized antisteroid, ZK98299 [onapristone, 11 beta-(4-dimethylaminophenyl)-17 alpha-hydroxy-17 beta-(3-hydroxypropyl)- 13 alpha-methyl-4,9-gonadien-3-one], in the calf uterus cytosol and compared the nature of this interaction with the binding of progesterone receptor (PR) agonist R5020 [promegestone, 17,21-dimethylpregna-4,9-diene-3,20-dione]. In the freshly prepared cytosol, [3H]ZK98299 interacted specifically with a macromolecule: the binding was abolished in the presence of excess progestins (R5020 and progesterone) and the antiprogesterone ZK98299. The high affinity (Kd = 2.5 nM) interaction between [3H]ZK98299 and PR was temperature- and time-dependent, reaching an optimum by 2-3 h at 0 degrees C, and was facilitated by 20 mM Na2MoO4. Under nontransforming conditions, [3H]ZK98299-receptor complexes sedimented as 8 S species in 8-30% linear glycerol gradients. Upon salt or thermal transformation, there was a loss of the 8 S form, with only a small fraction of total complexes (5-7%) binding to DNA-cellulose. In contrast, transformed [3H]R5020-receptor complexes exhibited a greater extent of binding (25-55%) to DNA-cellulose. [3H]ZK98299-receptor complexes could be resolved into two ionic species over DEAE-Sephacel following incubation of the complexes at 0 or 23 degrees C. [3H]ZK98299 binding was sensitive to sulfhydryl group modification as beta-mercaptoethanol increased the extent of steroid binding. Although treatment with iodoacetamide (IA) abolished [3H]R5020 binding, there was a significant (nearly twofold) increase in the [3H]ZK98299 binding. The results of this study point to similarities and differences between the steroid binding properties of the uterine PR occupied by R5020 and ZK98299: both steroids appear to bind the same 8 S receptor but exhibit differential DNA binding and sensitivity to IA. The reported antagonist properties of ZK98299 may, therefore, be explained on the basis of a distinct receptor conformation induced by the antisteroid.

ZK98299, a novel antiprogesterone that does not interact with chicken oviduct progesterone receptor

Steroid antagonists, at receptor level, are valuable tools for elucidating the mechanism of steroid hormone action. We have examined and compared the interaction of avian and mammalian progesterone receptors with progestins; progesterone and R5020, and a newly synthesized antiprogesterone ZK98299. In the chicken oviduct cytosol, [3H]R5020 binding to macromolecule(s) could be eliminated with prior incubation of cytosol with excess radioinert steroids progesterone or R5020 but not ZK98299. Alternatively, [3H]ZK98299 binding in the chicken oviduct was not abolished in the presence of excess progesterone, R5020, or ZK98299. In the calf uterine cytosol, [3H]R5020 or [3H]ZK98299 binding was competeable with progesterone, R5020 and ZK98299 but not estradiol, DHT or cortisol. Furthermore, immunoprecipitation and protein A-Sepharose adsorption analysis revealed that in the calf uterine cytosol, the [3H]R5020-receptor complexes were recognized by anti-progesterone receptor monoclonal antibody PR6. This antibody, however, did not recognize [3H]ZK98299-receptor complexes. When phosphorylation of progesterone receptor was attempted in the chicken oviduct mince, presence of progesterone resulted in an increased phosphorylation of the known components A (79 kDa) and B (110 kDa) receptor proteins. Presence of ZK98299 neither enhanced the extent of phosphorylation of A and B proteins nor did it reverse the progesterone-dependent increase in the phosphorylation. The avian progesterone receptor, therefore, has unique steroid binding site(s) that exclude(s) interaction with ZK98299. The lack of immunorecognition of calf uterine [3H]ZK98299-receptor complexes, suggests that ZK98299 is either interacting with macromolecule(s) other than the progesterone receptor or with another site on the same protein. Alternatively, the antisteroid binds to the R5020 binding site but the complex adopts a conformation that is not recognized by the PRG antibodies.