INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

The Double Burden of Malnutrition in Bangalore, India

The double burden of malnutrition (DBM), i.e., coexistence of under- and overnutrition, is an emerging issue in most of the low- and middle-income countries of the world. Using field survey data conducted in and around the city of Bangalore, India in 2018, we examine the patterns of DBM among women, young children (0-6 years), older children (7-18 years), and intrahousehold DBM between mothers and children. A unique aspect of the survey is that it is conducted in an area undergoing rapid urbanization, which is one of the factors responsible for DBM and can inform on the future of DBM in India. Compared to undernutrition, the prevalence of overnutrition is much higher in our study area. We find that, like other developing countries, the socioeconomic distance in prevalence of under- and overnutrition among women has decreased over time. Additionally, overnutrition among women is no longer an urban phenomenon. Similar trends were observed for older children. For younger children, on the other hand, the socioeconomic and locational differences persist, suggesting that this age group is not witnessing nutrition transition yet. The intrahousehold burden of DBM has also increased over time and the risk increases with maternal education. Although under- and overnutrition are opposite in nature, both have several common drivers, suggesting that an integrated approach might work better in tackling DBM. Several existing programs in India, such as ICDS, PDS, and the school meal program, provide excellent infrastructure to roll out policies and interventions, especially diet-based programs, aimed at both under- and overnutrition.

Clinicopathological profile of paroxysmal nocturnal haemoglobinuria clone-positive aplastic anaemia paediatric patients-A single centre study from North India

INTRODUCTION

There is a paucity of literature related to the prevalence of Paroxysmal Nocturnal haemoglobinuria (PNH) clones in paediatric aplastic anaemia (AA) patients.

METHODS

We performed a retrospective analysis over a period of 42 months to study the prevalence of PNH clones in paediatric (age less than 18 years) AA cases, using Fluorescein-labelled proaerolysin-based flow cytometric screening and analysed their clinico-pathological features.

RESULTS

PNH clone was identified in 100 (33.2%) of the 301 patients screened. These were comprised of 51 cases of non-severe AA, 33 cases of severe AA and 16 cases of very severe AA. The median age was 13 years with an M:F ratio of 2.5:1. The median clone size (taken as the proportion of PNH-positive neutrophils) was 2.15% (range: 0.05%-93.1%). Although a majority of patients (n = 77) had a clone size of less than 10%, a significant proportion (n = 23) did harbour a clone size of more than 10%. Evidence of haemolysis was observed in 3 patients, all of them having a clone size of more than 10%. Interestingly, 1 patient with dural sinus thrombosis harboured a clone size of 1.25% only. Chromosomal breakage analysis was performed in 61 patients, none of which was positive. Complete and partial response to immunosuppressive therapy was found in 55.1% patients (16/29).

CONCLUSION

There is a high prevalence of PNH clones in paediatric AA patients, which in a majority of cases are of small clone sizes. The use of immunosuppressive therapy does not show a better outcome as compared to PNH-negative cases.

The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Patients and Methods

Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score.

Results

The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5).

Conclusion

Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.

Sex-specific ultrasonic vocalization patterns and alcohol consumption in high alcohol-drinking (HAD-1) rats

Ultrasonic vocalizations (USVs) have been established as an animal model of emotional status and are often utilized in drug abuse studies as motivational and emotional indices. Further USV functionality has been demonstrated in our recent work showing accurate identification of selectively-bred high versus low alcohol-consuming male rats ascertained exclusively from 22 to 28kHz and 50-55kHz FM USV acoustic parameters. With the hypothesis that alcohol-sensitive sex differences could be revealed through USV acoustic parameters, the present study examined USVs and alcohol consumption in male and female selectively bred high-alcohol drinking (HAD-1) rats. For the current study, we examined USV data collected during a 12-week experiment in male and female HAD-1 rats. Experimental phases included Baseline (2weeks), 4-h EtOH Access (4weeks), 24-h EtOH Access (4weeks) and Abstinence (2weeks). Findings showed that both male and female HAD-1 rats spontaneously emitted a large number of 22-28kHz and 50-55kHz FM USVs and that females drank significantly more alcohol compared to males over the entire course of the experiment. Analyses of USV acoustic characteristics (i.e. mean frequency, duration, bandwidth and power) revealed distinct sex-specific phenotypes in both 50-55kHz FM and 22-28kHz USV transmission that were modulated by ethanol exposure. Moreover, by using a linear combination of these acoustic characteristics, we were able to develop binomial logistic regression models able to discriminate between male and female HAD-1 rats with high accuracy. Together these results highlight unique emotional phenotypes in male and female HAD-1 rats that are differentially modulated by alcohol experience.

Utility of a Paediatric Bleeding Questionnaire as a screening tool for von Willebrand disease in apparently healthy children

von Willebrand disease (VWD), an inherited bleeding disorder caused by deficiency or dysfunction of von Willebrand factor (VWF) is diagnosed when a personal and often a family history of excessive mucocutaneous bleeding is present along with abnormal laboratory studies. An accurate assessment of haemorrhagic symptoms is key in suspecting VWD but presents a challenge especially in children due to overlap between normal and abnormal bleeding. Bleeding questionnaire (BQ) scores have been validated in adults and have recently been validated in children with VWD for assessing bleeding severity. However, there are limited data supporting their use prospectively in healthy children with bleeding complaints.

AIM

The objectives of this study were to obtain normative data from children and validate a paediatric BQ (PBQ) to determine the discriminative ability of its total score and its individual components for identifying children likely to have VWD.

METHODS

The PBQ was administered to 1281 multiethnic, healthy children between 30 days and 18 years of age presenting to a general paediatric office and to 35 children with VWD based on VWF antigen, activity and multimer pattern.

RESULTS

When children with total BQ scores of 3 or more were predicted to have VWD, the sensitivity was 97.2%, the specificity was 97.1%, the positive predictive value was 48.6% and the negative predictive value was 99.9%.

CONCLUSIONS

The PBQ may help discriminate a significant bleeding history from trivial bleeding, may be integrated into the primary care algorithm for evaluating children suspected with VWD.

Zeolite membranes – a review and comparison with MOFs

The latest developments in zeolite and MOF membranes are reviewed, with an emphasis on synthesis techniques. Industrial applications, hydrothermal stability, polymer-supported and mixed matrix membranes are some of the aspects discussed.

Mitigating and adapting to climate change: multi-functional and multi-scale assessment of green urban infrastructure

In order to develop climate resilient urban areas and reduce emissions, several opportunities exist starting from conscious planning and design of green (and blue) spaces in these landscapes. Green urban infrastructure has been regarded as beneficial, e.g. by balancing water flows, providing thermal comfort. This article explores the existing evidence on the contribution of green spaces to climate change mitigation and adaptation services. We suggest a framework of ecosystem services for systematizing the evidence on the provision of bio-physical benefits (e.g. CO2 sequestration) as well as social and psychological benefits (e.g. improved health) that enable coping with (adaptation) or reducing the adverse effects (mitigation) of climate change. The multi-functional and multi-scale nature of green urban infrastructure complicates the categorization of services and benefits, since in reality the interactions between various benefits are manifold and appear on different scales. We will show the relevance of the benefits from green urban infrastructures on three spatial scales (i.e. city, neighborhood and site specific scales). We will further report on co-benefits and trade-offs between the various services indicating that a benefit could in turn be detrimental in relation to other functions. The manuscript identifies avenues for further research on the role of green urban infrastructure, in different types of cities, climates and social contexts. Our systematic understanding of the bio-physical and social processes defining various services allows targeting stressors that may hamper the provision of green urban infrastructure services in individual behavior as well as in wider planning and environmental management in urban areas.

Clinico-pathological impact of cytogenetic subgroups in B-cell chronic lymphocytic leukemia: experience from India

BACKGROUND

The present study of 238 B-cell Chronic Lymphocytic Leukemia (B-CLL) patients were undertaken to seek the prevalence and to evaluate clinico-pathological significance of recurrent genetic abnormalities such as del(13q14.3), trisomy 12, del(11q22.3) (ATM), TP53 deletion, del(6q21) and IgH translocation/deletion.

MATERIALS AND METHODS

We applied interphase - fluorescence in situ hybridization (FISH) on total 238 cases of B-CLL.

RESULTS

Our study disclosed 69% of patients with genetic aberrations such as 13q deletion (63%), trisomy 12 (28%), 11q deletion (18%), 6q21 deletion (11%) with comparatively higher frequency of TP53 deletion (22%). Deletion 13q displayed as a most frequent sole abnormality. In group with coexistence of ≥2 aberrations, 13q deletion was a major clone indicating del(13q) as a primary event followed by 11q deletion, TP53 deletion, trisomy 12, 6q deletion as secondary progressive events. In comparison with del(13q), trisomy 12, group with coexistence of ≥2 aberrations associated with poor risk factors such as hyperleukocytosis, advanced stage, and multiple nodes involvement. In a separate study of 116 patients, analysis of IgH abnormalities revealed either partial deletion (24%) or translocation (5%) and were associated with del(13q), trisomy 12, TP53 and ATM deletion. Two of 7 cases had t(14;18), one case had t(8;14), and four cases had other variant IgH translocation t(?;14).

CONCLUSION

Detail characterization and clinical impact are necessary to ensure that IgH translocation positive CLL is a distinct pathological entity. Our data suggests that CLL with various cytogenetic subsets, group with coexistence of ≥2 aberrations seems to be a complex cytogenetic subset, needs more attention to understand biological significance and to seek clinical impact for better management of disease.

Comparison of tolterodine with standard treatment in pediatric patients with non-neurogenic dysfunctional voiding/over active bladder: a systematic review

To examine the efficacy, safety and tolerability of tolterodine in children with overactive bladder in comparison with standard treatment i.e. oxybutynin as demonstrated in randomized clinical trials and other studies. A systematic search was done to screen the studies evaluating the effect of tolterodine in children with non-neurogenic overactive bladder. Results of studies were pooled and compared. Efficacy was determined from micturition diaries and dysfunctional voiding symptoms score. Safety and tolerability were assessed from the reported treatment emergent adverse events. A total of six randomized clinical trials and 11 other studies of tolterodine in children with urinary incontinence were included in the present systematic review. The dose of tolterodine used in different settings ranged from '0.5 to 8 mg/day' instead of '0.5 to 8 mg/kg per day' and the duration of studies ranged from 2 weeks to 12 months. Both extended and immediate release preparations of tolterodine were shown to have comparable efficacy and tolterodine proved to have comparable efficacy with better tolerability than oxybutynin in these studies. It can be concluded that tolterodine is efficacious in treatment of urinary incontinence in children. Moreover, its efficacy is comparable to oxybutynin, the most commonly prescribed anticholinergic in this condition, while having better tolerability. Hence, it can be considered as first line therapy for the treatmentof urinary incontinence in children.

Brown tumor of hyperparathyroidism involving craniomaxillofacial region: a rare case report and literature review

Central giant cell granuloma (CGCG) is a benign, non-odontogenic bone lesion of jaw. The condition is relatively infrequent and affects mainly children and young adults with a certain predominance among females and exhibits variable aggressiveness. Giant cell lesion associated with hyperparathyroidism is known as Brown tumor. Brown tumor is one of the bony complications of hyperparathyroidism. It is a giant cell granuloma which occurs in osteitis fibrosis cystica. It represents the terminal stage of the bone remodelling processes occurring as a result of peritrabecular fibrosis and osteoclastic activity. The mandible is the predominantly affected site in the maxillofacial area. Maxillary involvement is rare. The incidence of Brown tumor associated with hyperparathyroidism is rare (0.1%). Here, an extremely rare case of a 20 year old female patient with Brown tumor in her maxilla and mandible associated with primary hyperparathyroidism was presented. A thorough diagnostic work up showed presence of tumor mass in mandible and maxilla and elevated serum alkaline phosphatase and parathormone level and the patient was treated for both hyperparathyroidism and Brown tumor were discussed. The importance of different radiological evaluation methods and the consultation between the oral and maxillofacial surgeons, dentists, endocrinologists and radiologists were emphasized.

Systemic mastocytosis with associated acute myeloid leukemia with t (8; 21) (q22; q22)

Systemic mastocytosis with associated clonal hematological nonmast cell lineage disease (SM-AHNMD) is a subtype of mastocytosis associated commonly with myeloid neoplasms, Non-Hodgkin's lymphoma, or other hematological neoplasms. In these conditions, mastocytosis needs to be differentiated from mast cell hyperplasia or mast cell activation states. Neoplastic nature of mastocytosis is proved either by morphology, aberrant immunophenotype, or detection of point mutation at codon-816 of c-kit gene. This is a rare entity, even more so in pediatric population. Herein, we report a case of 14-year-old girl with SM associated with acute myeloid leukemia with maturation with t(8;21). Multifocal dense infiltrate of spindle-shaped mast cells on bone marrow aspirate and biopsy with coexpression of CD2 and CD25 by flow cytometric analysis proved the SM component at the time of diagnosis and persistence at post induction status also.

Light chain deposition disease in a postrenal transplant patient

The morphological spectrum of light chain deposition disease (LCDD) may range from normal glomerular morphology to mesangio-proliferative to mesangio-capillary to nodular sclerosing patterns. Due to the inconsistencies regarding treatment and the universally poor graft outcome of post-transplant LCDD, it is imperative to maintain a high index of suspicion and perform relevant investigations for clinching this diagnosis. A 40-year-old lady was diagnosed as a case of membrano-proliferative glomerulonephritis 3 years back, for which she underwent a live unrelated renal allograft transplant. Postoperative period was complicated by an acute rise in serum creatinine on the 21^st postoperative day. Biopsy showed patchy acute cortical necrosis, which responded to conservative management. The present admission was for renal failure and subnephrotic proteinuria. A kidney biopsy was performed, and all the 14 glomeruli examined showed a mesangiocapillary pattern of glomerular injury with cellular nodule formation in some. The nodules were PAS and Congo red negative. Immunofluorescence showed glomerular and tubular basement staining for Kappa light chains only. Electron microscopy showed the characteristic granular deposits in subendothelial location in the glomerulus, and in tubular basement membranes, thus confirming the diagnosis of LCDD. Membranoproliferative pattern of glomerular injury in the pre- and posttransplant setting has a wide range of differential diagnoses; LCDD being one of them.

Using a discrete choice experiment to elicit the demand for a nutritious food: willingness-to-pay for orange maize in rural Zambia

Using a discrete choice experiment, this paper estimates the willingness to pay for biofortified orange maize in rural Zambia. The study design has five treatment arms, which enable an analysis of the impact of nutrition information, comparing the use of simulated radio versus community leaders in transmitting the nutrition message, on willingness to pay, and to account for possible novelty effects in the magnitude of premiums or discounts. The estimation strategy also takes into account lexicographic preferences of a subset of our respondents. The results suggest that (a) orange maize is not confused with yellow maize, and has the potential to compete with white maize in the absence of a nutrition campaign, (b) there is a premium for orange maize with nutrition information, and (c) different modes of nutritional message dissemination have the same impact on consumer acceptance.

Tubulointerstitial nephritis with uveitis syndrome: A case report and review of literature

Tubulointerstitial nephritis with uveitis (TINU) syndrome is an unusual and under diagnosed cause of acute interstitial nephritis. The interstitial nephritis may precede, follow or develop concurrent to the uveitis. About 200 cases have been reported worldwide with only a single case reported from India. We report a 16-year-old male with TINU syndrome.

The effect of prostaglandin synthase inhibitor, aspirin on the rat intestinal membrane structure and function

Aspirin at a dose of 50 mg/kg body weight was found to decrease the activity of the rat intestinal brush border membrane (BBM) - associated enzymes such as the sucrase, lactase, maltase and alkaline phosphatase. Aspirin treatment also led to a decrease in the microviscosity in the native as well as the benzyl alcohol treated membrane which might be due to the lipid peroxidative damage in the membrane. Physical correlation of the membrane oxidative damage was evident as the Fourier Transformation Infra Red (FTIR) study of the Aspirin treated membrane, which include an increased proportion of gauche to trans conformer, shift in the methylene C-H asymmetric and symmetric stretching frequencies, C = O double bond stretching, NH bending, antisymmetric (N)-CH3 bending, C-N stretching and antisymmetric CNC stretching while there was no change in the CH2 wagging and twisting as well as in NH-bending amide bond I and II. Aspirin treatment also caused an alteration in the glucose and histidine transport, as evident by a decreased Vmax value while the apparent Km remaining unchanged in the control and Aspirin-treated animals confirming that there was no change in the substrate affinity constant of the membrane transport proteins for the glucose and the basic amino acid, although the rate of transport decreased considerably. There was a decrease noted in the energy of activation of glucose and histidine transport when studied at different temperature but no change in the temperature of phase transition in the BBM with Aspirin treatment, thus implying that perhaps the thermotropic phase transition in the membrane may have relatively little effect on the transport processes. The result suggests an underlying molecular mechanism indicating the implied membrane damage by Aspirin, an important member of the non-steroidal antiinflammatory drug (NSAID) family which could possibly through an oxidative damage may lead to an altered molecular structure, physical state and biological functions of the intestinal membrane.

Effect of non-steroidal anti-inflammatory drugs and the pro-carcinogen 1,2 dimethylhydrazine on the rat intestinal membrane structure and function

The present study was designed to evaluate the effects of three non-steroidal anti-inflammatory drugs (NSAIDs) with varying cycloxygenase selectivities on the small intestinal biochemical composition, function and histology during 1, 2-dimethylhydrazine (DMH) administration. Sprague Dawley male rats were divided into five different groups viz: Group 1 (control, vehicle treated), Group 2 (DMH-treated, 30 mg/kg body weight/week in 1 mM EDTA-saline, subcutaneously), Group 3 (DMH + aspirin-60 mg/kg body weight), Group 4 (DMH + celecoxib-6 mg/kg body weight), Group 5 (DMH + etoricoxib-0.64 mg/kg body weight). After six weeks of treatment, brush border membrane was isolated from the jejunum segment of all the groups and changes in the associated enzymes such as sucrase, lactase, maltase, alkaline phosphatase, membrane lipid composition, fluorescence polarizations of diphenylhexatriene, pyrene excimer formation, histological changes and surface characteristics were studied. The results indicated a significant alteration in the enzyme activity as well as changes in the structure and function of the intestine in the presence of the pro-carcinogen, DMH, which suggests the possible chemopreventive efficacy of NSAIDs against the intestinal cancer.

A neurosurgical hand rest

doi: 10.3126/kumj.v6i3.1727  Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 426-427

Intestinal transplantation for short bowel syndrome secondary to gastroschisis

BACKGROUND/PURPOSE

Gastroschisis is the most frequent cause of pediatric intestinal transplantation. This study reviews our experience of intestinal transplantation secondary to gastroschisis to elucidate those factors affecting the outcome of children with short bowel syndrome.

METHODS

A retrospective review was performed for children who underwent intestinal transplantation for gastroschisis at the University of Miami between June 2003 and August 1994.

RESULTS

Thirty-two transplants were performed in 28 children with gastroschisis during the study period. Associated intestinal anomalies were present in 22 infants (atresia [n = 14], volvulus [n = 3], and/or ischemia [n = 16]). Spontaneous prenatal closure of gastroschisis, a rare anomaly associated with bowel atresia and ischemia because of a very small abdominal defect, was seen in 9 patients. Most of the patients had a complicated course and required multiple abdominal surgeries before transplant. Fifteen (53.6%) patients are currently alive at a median follow-up of 23.5 months. Short-term survival rate has significantly improved in recent years.

CONCLUSIONS

Patients with complex gastroschisis and intestinal anomalies have a significant risk for progression to short bowel syndrome. Intestinal transplantation can be a lifesaving option and provides a satisfactory outcome for children with short bowel syndrome secondary to gastroschisis.

Etiology and Management of Alimentary Tract Ulcers in Pediatric Intestinal Transplantation Patients

Patients who undergo intestinal transplantation encounter several complications in the posttransplant period, one of them being ulcer formation in the alimentary tract. During postoperative endoscopic monitoring of 112 pediatric intestinal transplantation patients at our institution, we identified chronic ulcer formation in 11 patients. There were no common or defining demographic or clinical variables that were found in the patients with ulcers. The ulcers could be located within the allograft or in native tissue. Biopsies were obtained from the ulcer edge and the intervening mucosa as well as an evaluation of possible infectious agents. The most common changes in the ulcers were compatible with Epstein-Barr virus-associated posttransplant lymphoproliferative disorder (PTLD; seven cases), acute rejection (six cases), and less commonly, infectious causes (one case). These changes could occur concomitantly and retrospective analysis after therapy showed that the ulcers could have multiple etiologies. Directed biopsies of ulcer edges often displayed morphological changes compatible with acute rejection of the graft, although some biopsies of the intervening mucosa did not show similar changes. Some patients treated based on the changes within the intervening mucosa responded well and led to resolution of the ulcers. Our findings demonstrate that PTLD and acute rejection are the most common causes of chronic ulcer formation and that biopsy samples should be collected simultaneously from both the ulcer edge and intervening mucosa since pathological changes can vary depending on the underlying cause(s). Infectious agents were rarely present but could be seen superimposed with the underlying cause.

Zoom endoscopic monitoring of small bowel allograft rejection

BACKGROUND

The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection.

METHODS

A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope's accuracy in monitoring rejection.

RESULTS

Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy.

CONCLUSIONS

With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft.

Bacterial infections after intestine and multivisceral transplantation. The experience of the University of Miami (1994-2001)

BACKGROUND/AIMS

Bacterial infections (BI) are frequent after intestinal transplantation (ITx). Bacteremia, intraabdominal and respiratory infections are the leading forms. The objective of this study is to analyze the occurrence, determinants and outcome of BI.

METHODOLOGY

One hundred and twenty-four patients with ITx (39 isolated, 33 liver-intestine, 63 multivisceral). Only major BI were considered, including bacteremia, pneumonia, intraabdominal infections, severe wound infections.

RESULTS

BI occurred in 92.7% of patients during follow-up, with an average of 2.9 episodes per patient. Bacteremia was the commonest picture (1.7 per patient). More than 80% of patients had a BI before the end of the second month. Multivariate analysis showed that the presence of BI was higher during the first 2 months after Itx in patients hospitalized before Tx [p=0.029, odds ratio (OR) 5.4] and during months 3 to 6 in those treated with Zenapax (p=0.003, OR 6.2). Occurrence of BI was increased with mycophenolate mofetil treatment (p=0.045 OR 4.2). Intraabdominal infection was more frequent when reTx was needed (p=0.0178 OR 15.2), admission before Tx (p=0.034 OR 2.7), IS with MMF (p=0.004 OR 6.2) and Zenapax (p=0.026 OR 3.6). BI was the direct cause of death in 17.8% of patients, and it was present in 76.2% of patients that died. An infectious episode during the first month, a clinically manifested abdominal infection and a positive intraabdominal culture were determinants of shorter patient survival.

CONCLUSIONS

BI continue to be a frequent and dreadful complication after ITx. Pretransplant patient condition, IS used and postoperative complications are crucial on BI onset and outcome.

A computer reconstruction of the entire coronary arterial tree based on detailed morphometric data

A rigorous analysis of blood flow must be based on the branching pattern and vascular geometry of the full vascular circuit of interest. It is experimentally difficult to reconstruct the entire vascular circuit of any organ because of the enormity of the vessels. The objective of the present study was to develop a novel method for the reconstruction of the full coronary vascular tree from partial measurements. Our method includes the use of data on those parts of the tree that are measured to extrapolate the data on those parts that are missing. Specifically, a two-step approach was employed in the reconstruction of the entire coronary arterial tree down to the capillary level. Vessels > 40 microm were reconstructed from cast data while vessels < 40 microm were reconstructed from histological data. The cast data were reconstructed one-bifurcation at a time while histological data were reconstructed one-sub-tree at a time by "cutting" and "pasting" of data from measured to missing vessels. The reconstruction algorithm yielded a full arterial tree down to the first capillary bifurcation with 1.9, 2.04 and 1.15 million vessel segments for the right coronary artery (RCA), left anterior descending (LAD) and left circumflex (LCx) trees, respectively. The node-to-node connectivity along with the diameter and length of every vessel segment was determined. Once the full tree was reconstructed, we automated the assignment of order numbers, according to the diameter-defined Strahler system, to every vessel segment in the tree. Consequently, the diameters, lengths, number of vessels, segments-per-element ratio, connectivity and longitudinal matrices were determined for every order number. The present model establishes a morphological foundation for future analysis of blood flow in the coronary circulation.

Transplantation for the treatment of intra-abdominal fibromatosis

MATERIALS AND METHODS

During the last 9 years we treated 14 patients with a diagnosis of intra-abdominal fibromatosis. The 11 patients who received an intestinal allograft included isolated intestine (n = 6), liver-intestine (n = 1), intestine-kidney (n = 1), multivisceral (n = 1), multivisceral-kidney (n = 1), multivisceral-no liver (n = 1). Three patients received an intestinal autograft after partial abdominal evisceration and ex vivo tumor resection. Three patients additionally underwent an abdominal wall allograft.

RESULTS

At follow-up until August 2004, all autotransplant patients are alive. Four intestinal transplant patients died within the first postoperative month. There were three graft losses. A patient who lost his graft early postoperatively was retransplanted but died of sepsis shortly there after. Two more patients lost their graft due to severe rejection and were retransplanted successfully. Two patients developed desmoid tumor recurrence in their abdominal or thoracic wall. Ten patients are alive 1 to 9 years posttransplantation. Nine have fully functioning grafts and one patient requires TPN supplementation at night due to dysmotility of her autograft.

CONCLUSION

Intestinal allo-, or autotransplantation combined with transplantation of the abdominal wall can be lifesaving for patients suffering from extensive intra-abdominal fibromatosis.

Analysis of blood flow in the entire coronary arterial tree

A hemodynamic analysis of coronary blood flow must be based on the measured branching pattern and vascular geometry of the coronary vasculature. We recently developed a computer reconstruction of the entire coronary arterial tree of the porcine heart based on previously measured morphometric data. In the present study, we carried out an analysis of blood flow distribution through a network of millions of vessels that includes the entire coronary arterial tree down to the first capillary branch. The pressure and flow are computed throughout the coronary arterial tree based on conservation of mass and momentum and appropriate pressure boundary conditions. We found a power law relationship between the diameter and flow of each vessel branch. The exponent is ∼2.2, which deviates from Murray’s prediction of 3.0. Furthermore, we found the total arterial equivalent resistance to be 0.93, 0.77, and 1.28 mmHg·ml−1·s−1·g−1 for the right coronary artery, left anterior descending coronary artery, and left circumflex artery, respectively. The significance of the present study is that it yields a predictive model that incorporates some of the factors controlling coronary blood flow. The model of normal hearts will serve as a physiological reference state. Pathological states can then be studied in relation to changes in model parameters that alter coronary perfusion.

Trends in serum citrulline and acute rejection among recipients of small bowel transplants

A test for detecting acute cellular rejection (ACR) of small intestinal transplants (ITx) would be a major advance. Small preliminary studies suggest that serum citrulline levels correlate with ACR. The results for a group of 26 isolated intestinal and multivisceral transplant recipients are summarized here. Serum citrulline concentrations were determined by ion exchange chromatography and compared to biopsy-based grade of ACR. Other factors considered included patient and donor age and sex, ischemia time, and serum creatinine. Straight-line fits were employed to describe how each patient's citrulline levels changed over time. Estimated times to achieve normal citrulline (>or=30 micromol/L) ranged from 1 to 730 days posttransplant for 21 patients demonstrating increasing citrulline levels over time. Using stepwise linear regression, patients' ranks for time required to achieve normal citrulline levels were the only independent predictors of both maximum ACR (P <.0001) and average ACR (P =.0059) after 14 days posttransplant. The rate and direction of change in citrulline over time may be an indicator of the risk of acute rejection. We plan to further examine the use of citrulline as a marker for rejection in larger prospective studies.

Lymphoplasmacytic hyperplasia (possibly pre-PTLD) has varied expression and appearance in intestinal transplant recipients receiving Campath immunosuppression

Posttransplant lymphoproliferative disorders (PTLD) are a frequent complication in bowel transplant recipients. Histological changes in PTLD range from expansile lymphoplasmacytic (LP) hyperplasia to frank lymphoma. Small bowel allograft biopsies obtained in the first 250 days posttransplant were retrospectively graded after patients had received induction immunosuppression with either anti-CD52 (Campath) or anti-CD25 (Zenapax) monoclonal antibodies. The biopsies were analyzed with respect to the onset intensity of lymphoplasmacytic infiltrates and presence of in situ EBV hybridization (EBER) positivity. We observed that lymphoplasmacytic infiltrates were a frequent change in all bowel transplant patients over the examined period. Campath-treated patients developed earlier LP infiltrates of mild to moderate intensity between day 1 and 100 posttransplant, thereafter decreasing to mild. No EBER positivity was detected in this group. Zenapax-treated patients presented with LP infiltrates later of mild to moderate intensity through day 100 posttransplant. However, more persistent and intense LP infiltrates was observed after day 101 in this group, including a case of lymphoma and two cases of EBER positivity. We conclude that Campath immunosuppression results in an earlier appearance of LP lesions that are generally less intense than those evident with Zenapax. We attribute these findings to the more profound immunodeficiency and cell targeting following Campath treatment.

Sclerosing mesenteritis in small bowel transplantation: possible manifestation of acute vascular rejection

BACKGROUND

Acute rejection of human small bowel allografts is characterized by clinical symptoms combined with characteristic morphologic alterations. The typical geographic distribution of acute rejection in the bowel is involvement of the intestinal parenchyma, which can be transmural, particularly when the rejection is more severe. However, little is known concerning the potential for donor-derived soft tissue adjacent to the bowel to become involved by the host alloimmune response.

METHODS

We describe a male patient who, several weeks after combined small bowel and liver transplantation, demonstrated sclerosing mesenteritis with vasculitis and acute rejection of the bowel.

RESULTS

The vascular lesions in the mesentery demonstrated increased IgG deposition and the patient developed an alloantibody to the donor.

CONCLUSIONS

The changes described herein may represent a novel presentation of acute vascular rejection.

Immunoenzymatic and morphological detection of epithelial cell apoptotic stages in gastrointestinal allografts from multivisceral transplant patients

Acute allograft rejection (AR) is a major contributor to morbidity and mortality among patients who undergo multivisceral transplantation. Critical to the assessment of AR is detection of apoptosis in the glandular epithelium of the gastrointestinal allograft. We utilized the TUNEL stain (TdT-mediated biotin 16-dUTP nick-end labeling) to test whether this method improved detection of apoptosis compared to standard slide evaluation. TUNEL and H&E stains were performed on paraffin-embedded tissue sections to estimate the number of apoptotic bodies per 10 high power fields, as determined by independent pathologists in blinded fashion. Both methodologies showed similar numbers and distributions of apoptotic foci present among the epithelial cells. There was a correlation between the number of apoptosis and the grade of rejection (P <.001). This is the first use of the TUNEL stain in gastrointestinal allograft biopsies to our knowledge. The similarity in pattern and sensitivity of TUNEL with standard morphology confirms that biopsy assessment with routine H&E staining allows an accurate appraisal of epithelial cell apoptosis. Therefore, current staining protocols for endoscopically derived mucosal biopsies of gastrointestinal allografts are sufficiently accurate to enumerate the critical feature of epithelial apoptosis as a determinant of the grade of acute rejection.

Multivisceral transplantation for pediatric intestinal pseudo-obstruction: single center's experience of 16 cases

Chronic intestinal pseudo-obstruction (CIPO) in children may be life-threatening due to the complications of parenteral nutrition (PN) or catheter-related sepsis. Multivisceral transplantation (MVTx) is a lifesaving option but limited experience is available. We report our experience with MVTx in pediatric CIPO patients. Sixteen children with CIPO underwent MVTx at median age of 4 years. Indications for MVTx were liver failure (n = 10), loss of venous access (n = 3), or sepsis (n = 3). Modified MVTx without the liver was performed in six patients. Induction immunosuppression included tacrolimus, steroid with adjunctive agent in period I (April 1996 to December 2000), namely, OKT3 (n = 1), mycophenolate mofetil (n = 4), or daclizumab (n = 2); and in period II (January 2001 to present), Campath 1H (n = 4) or daclizumab (n = 5). The grade of rejection was severe in 12.5% and mild to moderate in 87.5% of cases. Isolated rejection of the transplanted stomach or pancreas was not diagnosed during clinical course or on autopsy. Actuarial patient survival for 1 year/2 years for period, I and II were 57.1%/42.9% and 88.9%/77.8%. None of the long-term survivors is on PN and all tolerate enteral feedings. Pancreatic enzyme supplementation or insulin therapy is not needed in survivors. Gastric emptying was substantially affected in one case. Bladder function did not improve in those with urinary retention problems. MVTx for CIPO offers a lifesaving option with excellent function of the transplanted pancreas and stomach among survivors.

Neurodevelopmental outcomes of infant intestinal transplant recipients

Little is known about the impact of intestinal transplantation on development of the infant brain. In this study we report four neurodevelopmental studies on children receiving either liver or intestinal/multivisceral transplants. Our preliminary investigation examined the pretransplant status of 27 infants, who were either liver or intestinal/multivisceral candidates, using the Bayley Scales of Infant Development. A second study examined 23 infants after liver or intestinal/multivisceral transplant. A third study included pre- and posttransplant evaluations on 5 multivisceral infant transplants. In the fourth study, 10 children were tested several years after intestinal/multivisceral transplantation. Some children are able to achieve a normal development. However, even several years posttransplant most children can still experience significant cognitive delays. Children receiving a transplant during infancy may also suffer severe motor delays. Infants undergoing intestinal/multivisceral transplantation show significantly more cognitive delays than those undergoing single-organ liver transplantation. In addition, multivisceral transplanted infants are more likely to continue to be severely developmentally delayed at the time of hospital discharge. With improved survival rates for infant transplants, both cognitive and motor development must be evaluated to determine the need for early intervention. In addition, educating families on the importance of compliance with intervention services outside the hospital is essential to maximize long-term neurodevelopmental outcomes for these infants.

Campath-1H immunosuppressive therapy reduces incidence and intensity of acute rejection in intestinal and multivisceral transplantation

Campath-1H, an anti-CD52 antibody, is being used at our institution as immunosuppression in multivisceral and intestinal transplantation. We reviewed the pathologic findings of 1696 small bowel allograft biopsies obtained in the first 250 days posttransplant from 78 patients who underwent isolated intestinal or multivisceral transplantation and received induction immunosuppression with Campath (n = 30) or Zenapax (n = 57). We found an overall reduced incidence of acute cellular rejection (ACR) in patients receiving Campath (19.1%) compared with those on Zenapax (32.8%). The majority of Campath patients showed no rejection or was indeterminate for rejection over the period of measurement. The frequencies of mild and moderate ACR were approximately twice and three times more common, respectively, in Zenapax-treated patients. The mean grade of ACR in Campath patients compared with Zenapax patients was significantly lower (P <.01) during the first 6 weeks posttransplant. Thereafter, the grade of rejection in both patient groups showed fluctuation, with Zenapax patients sometimes having lower values (eg, at 2 to 4 months) than Campath patients. Patient and graft survival was not significantly different between the two groups. These data suggest that the incidence of ACR is significantly reduced with Campath during the first 2 months posttransplant, when compared with Zenapax. However, the incidence and intensity of ACR following this initial time period shows vacillation with both types of immunosuppression.

Bacterial infections after intestine and multivisceral transplantation

BACKGROUND

The frequency of bacterial infections (BI) in intestinal transplant (IT) patients is high with sepsis being the leading cause of death after this procedure. We herein report our experience with major BI to ascertain the incidence, microbiological and clinical factors, risk factors and outcome.

MATERIALS AND METHODS

124 patients (72 children and 52 adults) received 135 grafts: namely, 39 isolated intestine, 33 liver-intestine and 63 multivisceral. Only major BI were considered, namely, those associated with serious morbidity/mortality requiring specific therapy. Patient data were retrieved from computerized databases, flow-charts, and medical records.

RESULTS

92.7% patients showed BI. There were 327 episodes, representing 2.6 episodes/patient (2.8/patients with infection): 193 episodes of bacteremia (1.7/patient with BI) including 29.5% due to catheter related sepsis, 16.5% from abdominal source, 5.7% from respiratory origin and 4.1% from the wound. The organ locations includes 46 respiratory infections, 33 intraabdominal abscesses or infected fluid collections, 8 diffuse peritonitis, 34 wound infections and other miscellaneous sites: empyema, soft tissue infections, cholangitis em leader etc. Median time of infection was nine days after surgery (mean 22+/-3 days), with 67.7% patients having at least one BI before the end of the first month. Infection was present in 76.2% of the 63 deceased patients. An infectious episode during month 1, a clinically manifest abdominal infection and a positive intraabdominal culture had negative impacts on patient survival.

CONCLUSIONS

BI are common and early complications after IT. The high rate of bacteremia, line sepsis and abdominal and respiratory infections reflect the recipient's condition, with chronic deterioration superimposed with the effects of prolonged abdominal visceral surgery.

Intestinal transplantation: advances in immunosuppression and surgical techniques

Campath-1H is being used as induction immunosuppression for intestinal/multivisceral transplantation. Patient and graft survival in this preliminary experience is similar to previous studies but there has been a significant decrease in the incidence and severity of acute rejections without increase of opportunistic infections. Collage of the abdominal wall (transplantation of a composite graft of the abdominal wall) can provide biologic coverage of the newly transplanted abdominal organs if necessary. Partial abdominal exenteration, ex vivo resection, and intestinal autotransplantation may be useful in removing otherwise unresectable lesions of the root of the mesentery.

The clinical spectrum of fibrocalculous pancreatic diabetes in north India

BACKGROUND

Fibrocalculous pancreatic diabetes (FCPD) is a secondary form of diabetes, unique to tropical countries. In earlier reports, patients with FCPD had severe insulin-requiring diabetes, malnutrition and a dismal prognosis. With Improvements in nutrition and medical care, the presentation and prognosis of FCPD may have changed. We report on the clinical profile and prognosis of a cohort of FCPD patients from north India and compare our findings with earlier reports.

METHODS

Eighty consecutive FCPD patients who presented to the Diabetes, Gastroenterology and Surgical Gastroenterology services were evaluated for their nutritional status, clinical presentation, beta-cell function (fasting C-peptide) and exocrine function (faecal chymotrypsin). All patients diagnosed between 1994 and 2000 (n = 32) were followed prospectively for weight gain and glycaemic control.

RESULTS

Only 55% of FCPD patients had a low body mass index (< 18 kg/m2). At the time of diagnosis of diabetes, only 26 (33%) patients presented with severe insulin-requiring diabetes; these patients were younger [23.7 (8.3) years v. 28.7 (10.6) years, p = 0.04], and had higher haemoglobin A1c [9.7 (3.8)% v. 7.3 (2.6)%, p = 0.005] than those requiring diet control or oral hypoglycaemic agents. FCPD patients had a wide range of fasting serum C-peptide (0.03-0.76 nmol/L). C-peptide was negatively associated with increasing duration of diabetes (r = -0.48, p = 0.001), but there was no correlation with faecal chymotrypsin. On prospective follow up (mean 2.3 years), there was significant improvement in body mass index [19.4 (2.9) kg/m2 v. 17.0 (3.7) kg/m2, p < 0.01] and haemoglobin A,c [6.4 (1.6)% v. 8.0 (3.0)%, p < 0.001].

CONCLUSION

FCPD patients differed from those described in earlier reports in many respects, Including improved nutritional status, a wide range of 3cell function and a more favourable prognosis.