Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Concomitant pulmonary disease is common among patients with extrapulmonary TB

BACKGROUND :

Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB).

METHODS :

We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018.

RESULTS :

Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16).

CONCLUSIONS :

A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.

A Rare Case of Large Left Lateral Wall Vaginal Myoma

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Clinical Estimation of Fetal Weight with Reference to Johnson's Formula: An Alternative Solution Adjacent to Sonographic Estimation of Fetal Weight

Background Fetal weight estimation plays a significant role in the antenatal management of high risk pregnancies. It is also an important parameter for predicting the neonatal outcome and informs decision for the mode of intra-partum management of the pregnant women. Among the various methods of prenatal fetal weight estimation, the most commonly used are clinical estimation and sonography. Objective The objective of this study was to compare the accuracy of clinical estimation of fetal weight using Johnson's formula and sonographic estimation with actual birth weight. Method This prospective study was conducted at Dhulikhel Hospital, Kathmandu University Hospital, from January 2017 to August 2018. The study included 335 pregnant women at term gestation. Result The estimation of fetal weight at term pregnancy using Johnson's formula is as effective as sonological method. For clinical method, the fetal weight falls between 95 gm and 183 gm at 95% confidence interval. With respect to ultrasound method, the fetal weight is found to be 45 gm and 132 gm at 95% confidence interval at p value < 0.001. Conclusion Clinical estimation of fetal weight can be utilized as an alternative to sonological estimation in the management of labor and delivery. Johnson's formula is a simple, easy, cost-effective, and universally applicable method to predict fetal birth weight and can be used anywhere by doctors, nurses, midwives and paramedics in centers where ultrasound is not available.

The Study of Burden of Family Caregivers of Patients Living with Psychiatric Disorders in Remote Area of Nepal

Background Family caregivers of psychiatric disorders likely to face burden. There is a paucity of data regarding the caregiver burden in psychiatric disorders in context of Nepal. Objective To study the caregiver burden in families with psychiatric illness and to find association between socio-demographic variables and caregiver burden in families with psychiatric illness. Method This is an analytical cross-sectional study. The participants (n=96) were caregiver of patients visiting outpatient department of two government of Nepal primary health care centers namely, Panchkhal Primary Health Care Center (PHC) Kavre District and Barhabise Health Care Center Sindhupalchowk district. The sample size has been determined by using statistical formula. Family burden assessment schedule (FBIS) was used for the study. Result The majority of the caregivers were females 56.3%. Most of the caregivers were aged below 45 years 54.2%. The large number of participants were single or separated 74%. The mean score of family burden assessment schedule was 27 ± 9.8 (range 0 to 48) with positive rate of 59.4%.Among the objective burden domains disruption of family leisure 61.5% was the most frequently reported burden. The subjective burden was reported in 95%. There were significant differential demographic associations with different domains of caregivers' burden. Conclusion Caregivers of Psychiatric patients experience different kind of burden of care. Our findings highlight the support to the family members to reduce their burden.

Respiratory health status is associated with treatment outcomes in pulmonary tuberculosis

<sec id="st1"> <title>BACKGROUND</title> The association between respiratory impairment and tuberculosis (TB) treatment outcomes is not clear. </sec> <sec id="st2"> <title>METHODS</title> We prospectively evaluated respiratory health status, measured using the Saint George's Respiratory Questionnaire (SGRQ), in a cohort of new adult pulmonary TB cases during and up to 18 months following treatment in India. Associations between total SGRQ scores and poor treatment outcomes of failure, recurrence and all-cause death were measured using multivariable Poisson regression. </sec> <sec id="st3"> <title>RESULTS</title> We enrolled 455 participants contributing 619 person-years at risk; 39 failed treatment, 23 had recurrence and 16 died. The median age was 38 years (interquartile range 26-49); 147 (32%) ever smoked. SGRQ scores at treatment initiation were predictive of death during treatment (14% higher risk per 4-point increase in baseline SGRQ scores, 95%CI 2-28, P = 0.01). Improvement in SGRQ scores during treatment was associated with a lower risk of failure (1% lower risk for every per cent improvement during treatment, 95%CI 1-2, P = 0.05). Clinically relevant worsening in SGRQ scores following successful treatment was associated with a higher risk of recurrence (15% higher risk per 4-point increase scores, 95%CI 4-27, P = 0.004). </sec> <sec id="st4"> <title>CONCLUSION</title> Impaired respiratory health status was associated with poor TB treatment outcomes. The SGRQ may be used to monitor treatment response and predict the risk of death in pulmonary TB. </sec>.

Assessment of the Xpert assay among adult pulmonary tuberculosis suspects with and without diabetes mellitus

SETTING: Pune and Pimpri-Chinchwad Municipal Corporation area, Maharashtra State, India.OBJECTIVE: To assess the sensitivity and specificity of the Xpert® MTB/RIF assay among adults with suspected pulmonary tuberculosis (PTB) and with or without diabetes (DM).DESIGN: As part of a prospective cohort study, we screened 2359 adults presumed to have PTB with no history of TB. All individuals underwent testing for two sputum smears, culture, Xpert, glycated haemoglobin and fasting blood sugar. We calculated sensitivity and specificity of Xpert by comparing it with TB sputum culture result as a gold standard.RESULTS: Among screened individuals, 483 (20%) were diagnosed with DM and 1153 (49%) with pre-DM; 723 (31%) had no DM. Overall sensitivity of Xpert was 96% (95%CI 95–97) and specificity was 91% (95%CI 89–93). Xpert sensitivity was significantly higher among DM group (98%) than in the ‘No DM' (95%; P < 0.01) and pre-DM (96%; P < 0.05) groups. Among sputum smear-negative individuals, Xpert sensitivity was higher in the DM group than in the No DM (92% vs. 82%; P = 0.054) and pre-DM group (92% vs. 82%; P = 0.037).CONCLUSION: High sensitivity and specificity of Xpert underscores the need for its rapid scale up for the early detection of TB in settings with a high dual burden of TB and DM.

Perennial malaria transmission and its association with rainfall at Kalahandi district of Odisha, Eastern India: A retrospective analysis

India contributes substantially to global malaria incidents. Vector dynamics is the significant determinant of malaria risk. Hence, knowledge on the interaction between rainfall, malaria cases and malaria vector density can be very useful for controlling malaria transmission. Kalahandi was screened for malaria cases, Anopheline vector density and their temporal relationship with rainfall. Epidemiological data was obtained from National Vector Borne Disease Control Programme, Odisha, India. Three years vector population study was carried out. Rainfall data was obtained from a database maintained by the Govt. of Odisha and was analysed using Univariate ANOVA and Pearson correlation co-efficient tests using R-prog. Malaria was found to be prevalent throughout the year attaining peak between July to August and another peak in December, amidst which the clinical malaria cases being recorded implied highest incidents in the month of July. The results estimated the seasonality of the population of An. culicifacies, An. fluviatilis and An. annularis over the region and determined the influence of rainfall on the vector population dynamics. Simple linear regression analysis suggested that at one month lag monthly rainfall (P=0.0007) was a significant meteorological factor. Rainfall seemed to be one of the best malaria predictors because of its positive correlation with proliferation of malaria cases in conjunction with An. culicifacies density making malaria a serious health issue in Kalahandi.

Trends in HbA1c levels and implications for diabetes screening in tuberculosis cases undergoing treatment in India

SETTING

The optimal timing of screening for diabetes mellitus (DM) among tuberculosis (TB) cases is unclear due to the possibility of stress hyperglycemia.

DESIGN

We evaluated adult (18 years) pulmonary TB cases at treatment initiation as well as at 3 months, 6 months and 12 months. DM was identified by self-report (known DM) or glycated hemoglobin (HbA1c)  6.5% (new DM). Trends in HbA1c levels during treatment were assessed using non-parametric tests.

RESULTS

Of the 392 participants enrolled, 75 (19%) had DM, 30 (40%) of whom had new DM. Of the 45 participants with known DM, respectively 37 (82%) and 40 (89%) received medication to lower glucose levels at treatment initiation and completion; one participant with new DM initiated glucose-lowering medication during follow-up. The median HbA1c level in participants with known, new and no DM was respectively 10.1% (interquartile range [IQR] 8.3-11.6), 8.5% (IQR 6.7-11.5) and 5.6% (IQR 5.3-5.9) at treatment initiation, and 8.7% (IQR 6.8-11.3), 7.1% (IQR 5.8-9.5) and 5.3% (IQR 5.1-5.6) at treatment completion (P < 0.001). Overall, 5 (12%) with known and 13 (43%) with new DM at treatment initiation had reverted to HbA1c < 6.5% by treatment completion (P = 0.003); the majority of reversions occurred during the first 3 months, with no significant reversions beyond 6 months.

CONCLUSION

HbA1c levels declined with anti-tuberculosis treatment. Repeat HbA1c testing at treatment completion could reduce the risk of misdiagnosis of DM.

Diabetes and pre-diabetes among household contacts of tuberculosis patients in India: is it time to screen them all?

SETTING

Pre-diabetes mellitus (pre-DM) and DM increase the risk of developing tuberculosis (TB). Screening contacts of TB patients for pre-DM/DM and linking them to care may mitigate the risk of developing TB and improve DM management.

OBJECTIVE

To measure the prevalence of pre-DM/DM and associated factors among the adult household contacts (HHCs) of pulmonary TB patients.

METHODS

Between August 2014 and May 2017, adult HHCs of newly diagnosed adult PTB patients in Pune and Chennai, India, had single blood samples tested for glycosylated haemoglobin (HbA1c) at enrolment. DM was defined as previously diagnosed, self-reported DM or HbA1c 6.5%, and pre-DM as HbA1c between 5.7% and 6.4%. Latent tuberculous infection (LTBI) was defined as a positive tuberculin skin test (5 mm induration) or QuantiFERON® Gold In-Tube (0.35 international units/ml).

RESULTS

Of 652 adult HHCs, 175 (27%) had pre-DM and 64 (10%) had DM. Forty (64%) HHCs were newly diagnosed with DM and 48 (75%) had poor glycaemic control (HbA1c 7.0%). Sixty-eight (22%) pre-DM cases were aged 18-34 years. Age 35 years, body mass index 25 kg/m2, chronic disease and current tobacco smoking were significantly associated with DM among HHCs.

CONCLUSIONS

Adult HHCs of TB patients in India have a high prevalence of undiagnosed DM, pre-DM and LTBI, putting them at high risk for developing TB. Routine DM screening should be considered among all adult HHCs of TB.

A comparative study of prevalence and spatial distribution of major Anopheline vector fauna in a hyper- and a hypomalaria endemic district of Odisha, India with special reference to onset of first wet season

The state's retrospective findings indicate the incidence of malaria deaths, which is more during the onset of first monsoon season. Based upon this fact, our objective was to study the distribution pattern of major Anopheles vectors in two endemic districts viz. Kalahandi and Cuttack of Odisha, India that differ significantly according to malariogenic stratification, under the impact of first monsoon shower. A comparative study of vector abundance, predominance, their habitats, resting site preference, impact of abiotic rhythm (light/dark period) on vector distribution, gonotrophic status as well as sporozoite rate was established in a high and a low endemic district of Odisha, when the degree of malaria transmission elevates to its peak level Anopheles culicifacies was found to be predominant in hyperendemic Kalahandi district while Anopheles subpictus was abundant in hypo-endemic Cuttack district. Both primary vector An. culicifacies and the secondary vector An. subpictus mostly prefer CS (Cattle shed) compared to HD (Human dwelling) in Kalahandi district where as there was slight shifting of resting habitat of An. culicifacies from CS to HD in Cuttack district. Anopheles culicifacies prefers to rest on wall besides objects in Kalahandi while no such site preference was observed in Cuttack district. On the other hand, distribution of An. subpictus was highly influenced by the daily rhythm of light/dark cycle (i.e. day and night) in Cuttack. The gonotrophic condition revealed the high tendency of the predominant vectors towards endophilic resting. The sporozoite rate was 0.66% in Kalahandi and nil in Cuttack district. The proper monitoring of vector prevalence and distribution, at least during the peak transmission period can avert a perpetuated upsurge in malaria.

Prevalence of dysglycemia and clinical presentation of pulmonary tuberculosis in Western India

SETTING

Pune, India.

OBJECTIVES

To estimate the prevalence and risk factors of pre-diabetes mellitus (DM) and DM, and its associations with the clinical presentation of tuberculosis (TB).

DESIGN

Screening for DM was conducted among adults (age  18 years) with confirmed TB between December 2013 and January 2017. We used multinomial regression to evaluate the risk factors for pre-DM (glycated hemoglobin [HbA1c]  5.7-6.5% or fasting glucose 100-125 mg/dl) and DM (HbA1c  6.5% or fasting glucose  126 mg/dl or random blood glucose > 200 mg/dl or self-reported DM history/treatment) and the association of dysglycemia with the severity of TB disease.

RESULTS

Among 1793 participants screened, 890 (50%) had microbiologically confirmed TB. Of these, 33% had pre-DM and 18% had DM; 41% were newly diagnosed. The median HbA1c level among newly diagnosed DM was 7.0% vs. 10.3% among known DM (P < 0.001). DM (adjusted OR [aOR] 4.94, 95%CI 2.33-10.48) and each per cent increase in HbA1c (aOR 1.42, 95%CI 1.01-2.01) was associated with >1+ smear grade or 9 days to TB detection.

CONCLUSION

Over half of newly diagnosed TB patients had DM or pre-DM. DM and increasing dysglycemia was associated with higher bacterial burden at TB diagnosis, potentially indicating a higher risk of TB transmission to close contacts.

Learning Curve for Laparoscopic Hysterectomy: An Experience from Kathmandu University Hospital

Aims: The aim of this study is to assess learning curves for laparoscopic hysterectomies, compare the performance of surgeons and review demographic parameters of the patients, varieties of complications experienced and indications of the procedures. Methods: A retrospective study was conducted in Kathmandu University Hospital, Kavre of January 1, 2011 to June 30, 2018. Results: A total of 1849 cases were already performed by mid 2018. Of them, 261 (14.12%) cases were LAVH and TLH cases. Mean duration for laparoscopic hysterectomies (for both LAVH and TLH) was 142.21±43.46 minutes (range 55 to 310 minutes) and one third of the cases performed in a range of 121 to 150 minutes. There is difference in mean duration of operation between surgeons which is statistically significant (p <0.001). Beside one of four surgeons (surgeon B) had significant reduction in mean duration for LAVH surgery (p=0.004). Same surgeon has significant reduction in mean duration for performing TLH (p=0.0047). Of the 261 laparoscopic hysterectomies, 8 cases (3.07%) turned into laparotomy. Conclusions: Laparoscopic hysterectomies are feasible with reducing mean operating time across the period. These minimal invasive surgeries are safe with low rate of complications and less conversion to open even in our set up.

Fetomaternal outcome in elevated Glucose Challenge Test and gestational diabetes

Aims: To observe the maternal and fetal outcome among those having elevated Glucose Challenge Test (GCT) level and gestational diabetes mellitus (GDM).Methods: Medical record of 15,413 pregnant women booked and delivered between June 2012 and January 2018 were evaluated. GCT was performed by using 50gm glucose and diagnosis of gestational diabetes performed by using the Carpenter Coustan Criteria. Pregnancy outcomes were assessed by the antenatal events, gestation and mode of delivery. Similarly, neonatal outcomes assessed in terms of birth weights, Apgar score, congenital abnormalities, hyperbilirubinaemia, hypoglycaemia and respiratory distress syndrome.Results: The detected incidence of gestational diabetes was 2.35%. With the threshold plasma glucose level at 140 mg/ dl, 1843 women needed to undergo 100g oral glucose tolerance test and 363 women had gestational diabetes.Conclusions: It is very important to find out GDM in pregnancy as it has adverse outcomes which are preventable; it is worthwhile to detect GDM by screening in pregnancy. The 50g GCT is feasible and 100gm OGTT to find out GDM.

Temperature Controlled Evolution of Silver Polypods from Biomass Encapsulated Nano-Droplets

Silver nanoparticles are produced by a novel biosynthesis technique using fungus Penicillium purpurogenum NPMF (MTCC 7356). The biomass when subjected to heat treatment up to 700 °C produces the nanoparticles of silver due to the presence of free carbon which acts as encapsulation for silver nanoparticles. Increase in temperature above 700 °C causes a reduction in concentration of free carbon so that the nanoparticles come close to each other and form clusters in the shape of tetrapods to polypods. The micro-Raman analysis supports the formation of mesoporous carbon with increase in the calcined temperature. The formation of Ag nanostructures has been explained in terms of free energy diagram i.e., the crystal favors more to grow on (100) facet or (110) facet rather than on (111) facet by the addition of silver atoms and thereby, it releases more energy. The release of energy has been confirmed from the differential thermo gravimetric analysis. In fact, it is the dynamics of the minimization of the free energy of the system which governs the reorientation and rearrangement of Ag themselves leading to formation of various types of polypods. A formation mechanism is presented schematically.

Atypical Exciton-Phonon Interactions in WS2 and WSe2 Monolayers Revealed by Resonance Raman Spectroscopy

Resonant Raman spectroscopy is a powerful tool for providing information about excitons and exciton-phonon coupling in two-dimensional materials. We present here resonant Raman experiments of single-layered WS2 and WSe2 using more than 25 laser lines. The Raman excitation profiles of both materials show unexpected differences. All Raman features of WS2 monolayers are enhanced by the first-optical excitations (with an asymmetric response for the spin-orbit related XA and XB excitons), whereas Raman bands of WSe2 are not enhanced at XA/B energies. Such an intriguing phenomenon is addressed by DFT calculations and by solving the Bethe-Salpeter equation. These two materials are very similar. They prefer the same crystal arrangement, and their electronic structure is akin, with comparable spin-orbit coupling. However, we reveal that WS2 and WSe2 exhibit quite different exciton-phonon interactions. In this sense, we demonstrate that the interaction between XC and XA excitons with phonons explains the different Raman responses of WS2 and WSe2, and the absence of Raman enhancement for the WSe2 modes at XA/B energies. These results reveal unusual exciton-phonon interactions and open new avenues for understanding the two-dimensional materials physics, where weak interactions play a key role coupling different degrees of freedom (spin, optic, and electronic).

Non-mulberry Silk Fibroin Biomaterial for Corneal Regeneration

PURPOSE

Successful repair of a damaged corneal surface is a great challenge and may require the use of a scaffold that supports cell growth and differentiation. Amniotic membrane is currently used for this purpose, in spite of its limitations. A thin transparent silk fibroin film from non-mulberry Antheraea mylitta (Am) has been developed which offers to be a promising alternative. The silk scaffolds provide sufficient rigidity for easy handling, the scaffolds support the sprouting, migration, attachment and growth of epithelial cells and keratocytes from rat corneal explants; the cells form a cell sheet, preserve their phenotypes, express cytokeratin3 and vimentin respectively. The films also support growth of limbal stem cell evidenced by expression of ABCG2. The cell growth on the silk film and the amniotic membrane is comparable. The implanted film within the rabbit cornea remains transparent, stable. The clinical examination as well as histology shows absence of any inflammatory response or neovascularization. The corneal surface integrity is maintained; tear formation, intraocular pressure and electroretinography of implanted eyes show no adverse changes. The silk fibroin film from non-mulberry silk worms may be a worthy candidate for use as a corneal scaffold.

Pregnancy Related Acute Kidney Injury at a Tertiary Care Center in Nepal

Aims: This was performed to study the characteristics of Pregnancy Related Acute Kidney Injury (PRAKI), its management and outcome in patients at a tertiary level referral centre. Methods: A hospital based prospective observational study was conducted in Tribhuvan University Teaching Hospital (TUTH) over a period of 18 months. All patients diagnosed with PRAKI were included in the study. Patient profiles in terms of age, parity, gestational age were studied along with time of occurrence of PRAKI, preceding event, etiology, management and maternal outcome. Descriptive and univariate analyses were conducted and qualitative variables were expressed as percentages while quantitative variables as means. Results: There were fifteen cases of PRAKI during the study period with incidence of 2.1 per 1000 deliveries. The average age was 25.23± 3.8 years and 9(60%) were primipara. Fourteen (93.3%) developed PRAKI in the postpartum period with 10(66.6%) cases following Lower Segment Caesarian Section (LSCS). The commonest etiology of PRAKI was severe preeclampsia/ Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP) syndrome and pregnancy hemorrhages each consisting 4(26.6%) cases. The stage of Acute Kidney Injury (AKI) according to RIFLE (Risk, Injury, Failure, Loss, ESRD-End Stage Renal Disease) criteria was as follows: risk in 1(6.6%), injury in 3(20%) and failure in 11(73.3%) cases. Hemodialysis was necessary in 12(80%) cases while 3 cases (20%) improved with medical management only. The average duration of hospital stay was 25.2±14.7 days and 7(46.6%) needed ICU admission. Twelve (80%) cases recovered completely while two patients were dialysis dependent at the time of evaluation. There was one death. Conclusions: PRAKI occurred mainly in the postpartum period with severe preeclampsia/HELLP syndrome and hemorrhages as the most common causes. It is associated with high maternal morbidity, prolonged hospital stay and even mortality. Multidisciplinary team management is essential. 

Framework tool for a rapid cumulative effects assessment: case of a prominent wetland in Myanmar

The wetland of focus, Inle Lake, located in central Myanmar, is well known for its unique biodiversity and culture, as well as for ingenious floating garden agriculture. During the last decades, the lake area has seen extensive degradation in terms of water quality, erosion, deforestation, and biodiversity concomitant with a major shift to unsustainable land use. The study was conducted, with an emphasis on water quality, to analyze environmental impacts (effects) changing the ecosystem and to comprehensively evaluate the environmental state of the ecosystem through an innovative Rapid Cumulative Effects Assessment framework tool. The assessment started with a framework-forming Participatory Rural Appraisal (PRA), which quantified and prioritized impacts over space and time. Critically important impacts were assessed for "intra-inter interactions" using the loop analysis simulation. Water samples were analyzed while geographic information system (GIS) and remote sensing were used to identify water pollution hotspots. It was concluded that out of a plethora of impacts, pollution from municipal sources, sedimentation, and effects exerted by floating gardens had the most detrimental impacts, which cumulatively affected the entire ecosystem. The framework tool was designed in a broad sense with a reference to highly needed assessments of poorly studied wetlands where degradation is evident, but scarcely quantified, and where long-term field studies are fraught with security issues and resource unavailability (post-conflict, poor and remote regions, e.g., Afghanistan, Laos, Sudan, etc.).

Curcumin nanoparticles inhibit corneal neovascularization

Corneal neovascularization is a leading cause for compromised vision. Therapeutic prevention of corneal neovascularization is a major clinical challenge, and there is a compelling need to seek effective and safe therapy for this pathology. This study is aimed to evaluate curcumin nanoparticle for prevention of corneal neovascularization. MePEG-PCL nanoparticles were successfully prepared and characterized. The nanoparticle of curcumin has shown increased efficiency in preventing angiogenic sprouting in vitro. Topical delivery of curcumin nanoparticle in the eye showed enhanced retention of curcumin in the cornea, and significant improvement in prevention of corneal neovascularization over free curcumin as graded clinically and by histopathology; suppression in the expression of VEGF, inflammatory cytokines, and MMP was evidenced in the treated cornea. Curcumin inhibited NFκB in LPS-induced corneal cells. Histopathology and scanning electron microscopy showed absence of any adverse change in the corneal structure following application of curcumin nanoparticle. Therefore, we conclude that curcumin nanoparticle can be a potential candidate for prevention of corneal neovascularization.

KEY MESSAGE

• Curcumin nanoparticles show enhanced retention of curcumin in the cornea. • Curcumin NPs suppress the expression of VEGF, inflammatory cytokines, and MMP. • Curcumin NPs prevent corneal neovascularization by suppressing the NFκB pathway. • Curcumin NPs may be a promising candidate for prevention of corneal neovascularization.

Evaluation of spontaneous dense array gamma oscillatory activity and minor physical anomalies as a composite neurodevelopmental endophenotype in schizophrenia

OBJECTIVE

Minor physical anomalies (MPAs) and gamma oscillatory activity have been proposed as associated endophenotypes in schizophrenia. Combining these endophenotypes to create a composite endophenotype may help identify those at risk for schizophrenia better. The present study aims to investigate MPAs and gamma oscillatory activity in schizophrenia patients, their unaffected first degree relatives and healthy controls and appreciate whether they can be used together as a composite endophenotype.

METHODS

This was a cross sectional family study conducted at a tertiary care mental health setup. Ninety participants including schizophrenia patients, their first degree relatives and controls (thirty each) were assessed for MPAs on the Extended Waldrop Scale. All participants underwent an awake, resting 192-channel EEG recording. Spectral power and coherence in 30-100Hz gamma bands were estimated using Welch's averaged periodogram method. One-way ANOVA, chi square test were used for comparing socio-demographic-clinical variables. MANOVA supplemented by one-way ANOVAs (post hoc Tukey HSD) were done for comparison of spectral measures. Pearson's correlation, step-by-step linear discriminant functional and intra-familial correlation analysis were subsequently performed.

RESULTS

An endophenotype pattern of finding was found for MPAs in the craniofacial region, the total number of MPAs, spectral power in right temporal region on all bands and in the right parietal region in 50-70Hz and 70-100Hz gamma bands. The three groups were most accurately classified when MPA total score, right temporal 30-50Hz gamma power and right occipital 'intra hemispheric' 50-70Hz gamma coherence were considered together than when considered independently. Significant intra familial correlation was seen for MPA total score and right temporal gamma 30-50Hz power.

CONCLUSION

Composite evaluation of two developmentally linked markers i.e. MPAs and gamma spectral measures may prove useful in categorizing schizophrenia and identifying at-risk individuals.

Case report: boldo (Peumus boldus) and tacrolimus interaction in a renal transplant patient

INTRODUCTION

Boldo is an extract of a Chilean tree leave (Peumus boldus mol) that have been traditionally employed in folk medicine. We have presented a case of subtherapeutic tacrolimus levels in a renal transplant patient while taking boldo. In the literature search, no interaction has been reported between boldo and tacrolimus.

CASE REPORT

A 78-year-old Hispanic man with history of diabetes mellitus, hypertension, and deceased donor renal transplant in 2005 presented to the renal clinic for regular follow-up on September 1, 2010. No complaints were reported and physical examination was unremarkable. Laboratory tests taken on July 26, 2010, were significant for tacrolimus level of <3 ng/mL (measured by liquid chromatography/tandem mass spectrometry) and serum creatinine of 1.2 mg/dL (106 μmol/L). Medications included tacrolimus 2 mg bid and mycophenolate 500 mg bid. On further inquiry, the patient admitted taking herbal medication, boldo 300 mg bid, for the last few weeks. There was no change in his regular medications. He was adherent to his medication. He had been taking tacrolimus from the same company and pharmacy since August 2009. The last dose of boldo was on September 1, 2010. One week after he stopped taking boldo, tacrolimus level was 6.1 ng/mL (9/8/2010) on the same tacrolimus dose of 2 mg bid. Tacrolimus dose was increased to 3 mg bid (9/9/2010), awaiting tacrolimus levels. Subsequent levels (ng/mL) were 8.6 and 9.5, which made us resume the prior tacrolimus dose (2 mg bid).

CONCLUSIONS

We have reported a case of an allograft renal transplant recipient who presented to the clinic with subtherapeutic levels of tacrolimus while taking the herbal remedy boldo. Tacrolimus levels rose to the intended target after discontinuation of boldo. Although it is a single case report, our observation suggests a possible herb-drug interaction.

Factors Influencing Perception of Labor Pain among Parturient Women at Tribhuvan University Teaching Hospital

Aims: This study was done to understand the severity of labor pain in parturients of Kathmandu and to determine factors affecting it. Methods: A descriptive study was conducted in Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal where 300 term parturientsin active labor (cervical dilatation of 3-5 cm with three uterine contractions in 10 minutes each lasting for ≥ 30 seconds) were analysed for socio-demographic data, clinical profile and pain assessment.Visual analog scale was used for pain assessment. Results: The intensity of labor pain was graded as severe by 32%, moderateby 57% and mild by 11% of parturients.Almost half ofthe parturients in the age group of ≤19years described labor pain as severe as compared to women between 20-34years (30.4%) and ≥35years (20%). Among the nulliparous parturients, 37% described it as severe compared to only 20.7% in≥Para1.In those with≥higher secondary leveleducation, 35.9% described labor pain as severe as compared to those women who had education of ≤primary level(26.9%) and upto secondary level (27.1%). Labor pain was seen to be more severe in advanced labor withmore than half describingit as severe when the cervix was dilated to 5 cm, as compared to only 25.9% and 29.4% of the parturients at 3 and 4cm cervical dilatation respectively. Conclusions: This study concluded that the labor pain was moderate to severe for majority of the parturients.Adolescents, nullipara, patients with higher education and those in advanced laborwere more likely to perceive labor pain of higher intensity. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 26-30 DOI: http://dx.doi.org/10.3126/njog.v8i1.8857

Two step meso-acidophilic bioleaching of chalcopyrite containing ball mill spillage and removal of the surface passivation layer

Meso-acidophilic bacterial leaching of ball mill spillage (containing chalcopyrite >80%) was carried out in an innovative two-step bioleaching method. The major drawback of meso-acidophilic bioleaching limiting industrial application is the passivation phenomenon over the ore surfaces in iron-sulfur rich environments. In the present study, we present a novel wash solution that efficiently removed the passivation layer. FTIR characterization of the bioleached sample indicated that the residues could be further leached to recover extra copper after wash solution application. XRD study indicated accumulation of sulfates (SO(4)(-)) of Na, K, Fe and oxy hydroxides of iron [FeO(OH)] in the form of jarosite outlining the passivation layer. SEM, FESEM-EDS studies indicated severe corrosion effects of the wash solution on the passivation layer. Two step bioleaching of the ore sample yielded 32.6% copper in 68days in the first interlude and post wash solution application yielded 10.8% additional copper.

Extraction of nickel by microbial reduction of lateritic chromite overburden of Sukinda, India

Microbial extraction of nickel from lateritic chromite overburden (COB), Sukinda by Acidithiobacillus ferrooxidans has been investigated in this work. In anoxic environment, A. ferrooxidans reduced the ferric iron in goethite [Fe(O)OH] mineral of COB by using elemental sulphur as electron donor. Nickel embedded in the complex goethite matrix of COB was successfully recovered by cumulative action of sulphuric acid, generated by oxidation of elemental sulphur and reduction of ferric iron in goethite matrix by A. ferrooxidans. Forty one percent of the nickel present in COB was extracted in a 3 L scale bioreactor (pH of 1.8 ± 0.05, temperature of 28 ± 2°C) maintained in anoxic environment. In contrast, only 11% of the nickel present in COB was extracted with continuous supply of air to the bioreactor keeping all the parameters unchanged. Kinetics study of anoxic microbial processing of COB revealed that the chemical reaction rate control model fits to the rate of nickel dissolution (R(2)=0.975).

A randomized study comparing intravaginal prostaglandin (PGE2) with oxytocin for induction of labour in premature rupture of membrane at term

This is a prospective randomized study conducted in Tribhuvan University Teaching Hospital from February 2008 to January 2009. Total 72 women with Premature rupture of membranes (PROM) were included. Thirty-six women received PGE2 vaginal gel and thirty-six received iv oxytocin. Induction was successful in majority of cases in both the groups; 88.8% in PGE2 and 83.3% in oxytocin group (p value = 0.063). Time duration from induction to active stage was comparable (p value = 0.273). Induction to delivery interval was significantly low in oxytocin group (p value = 0.002) but leaking to delivery interval was similar in both the groups (p value = 0.083). PGE2 had slightly higher side effect than oxytocin. PGE2 and oxytocin were both effective and safe for induction of labour in women with PROM at term. There was no significant difference in maternal and fetal outcome, hospital stay, leaking to delivery interval, maternal and neonatal side effects, though induction to delivery interval was significantly less with oxytocin.

Spontaneous gamma coherence as a possible trait marker of schizophrenia-An explorative study

OBJECTIVES

Integration of sensory information by cortical network binding appears to be crucially involved in sensory processing activity. Studies in schizophrenia using functional neuroimaging, event-related potentials and EEG coherence indicate an impairment of cortical network coupling in this disorder. Previous electrophysiological investigations in animals and humans suggested that gamma activity (oscillations at around 30-100Hz) is essential for cortical network binding. This is the first investigation of spontaneous gamma activity in schizophrenics and their first degree relatives as compared to normal controls.

METHOD

Resting EEG was recorded in 20 drug naïve/drug free male schizophrenic patients, their pair matched male first degree relatives and 20 age-, sex-, education- and handedness-matched normal controls. Power spectrum and coherence of gamma band activity was analysed using MATLAB 6.5.

RESULTS

Schizophrenic patients had significantly less interhemispheric spontaneous gamma coherence and increased gamma power compared to normal controls. But there was no significant difference in gamma coherence between patients and their first degree relatives. Spontaneous gamma coherence had significant correlation with few PANSS subscale scores.

CONCLUSIONS

There is cortical hyperactivation and a reduced spontaneous and induced gamma coherence abnormality in schizophrenia. The abnormal gamma coherence appears explaining the psychopathology and poor performance on cognitive task in schizophrenia. This study has also generated hypotheses that the gamma band abnormality may be a trait abnormality in schizophrenics as seen by the similarity between the patient and their clinically asymptomatic first degree relatives.

Manganese biomining: A review

Biomining comprises of processing and extraction of metal from their ores and concentrates using microbial techniques. Currently this is used by the mining industry to extract copper, uranium and gold from low grade ores but not for low grade manganese ore in industrial scale. The study of microbial genomes, metabolites and regulatory pathways provide novel insights to the metabolism of bioleaching microorganisms and their synergistic action during bioleaching operations. This will promote understanding of the universal regulatory responses that the biomining microbial community uses to adapt to their changing environment leading to high metal recovery. Possibility exists of findings ways to imitate the entire process during industrial manganese biomining endeavor. This paper reviews the current status of manganese biomining research operations around the world, identifies factors that drive the selection of biomining as a processing technology, describes challenges in exploiting these innovations, and concludes with a discussion of Mn biomining's future.

Clonal analysis of the microbiota of severe early childhood caries

BACKGROUND/AIMS

Severe early childhood caries is a microbial infection that severely compromises the dentition of young children. The aim of this study was to characterize the microbiota of severe early childhood caries.

METHODS

Dental plaque samples from 2- to 6-year-old children were analyzed using 16S rRNA gene cloning and sequencing, and by specific PCR amplification for Streptococcus mutans and Bifidobacteriaceae species.

RESULTS

Children with severe caries (n = 39) had more dental plaque and gingival inflammation than caries-free children (n = 41). Analysis of phylotypes from operational taxonomic unit analysis of 16S rRNA clonal metalibraries from severe caries and caries-free children indicated that while libraries differed significantly (p < 0.0001), there was increased diversity than detected in this clonal analysis. Using the Human Oral Microbiome Database, 139 different taxa were identified. Within the limits of this study, caries-associated taxa included Granulicatella elegans (p < 0.01) and Veillonella sp. HOT-780 (p < 0.01). The species associated with caries-free children included Capnocytophaga gingivalis (p < 0.01), Abiotrophia defectiva (p < 0.01), Lachnospiraceae sp. HOT-100 (p < 0.05), Streptococcus sanguinis (p < 0.05) and Streptococcus cristatus (p < 0.05). By specific PCR, S. mutans (p < 0.005) and Bifidobacteriaceae spp. (p < 0.0001) were significantly associated with severe caries.

CONCLUSION

Clonal analysis of 80 children identified a diverse microbiota that differed between severe caries and caries-free children, but the association of S. mutans with caries was from specific PCR analysis, not from clonal analysis, of samples.

Diet and caries-associated bacteria in severe early childhood caries

Frequent consumption of cariogenic foods and bacterial infection are risk factors for early childhood caries (ECC). This study hypothesized that a short diet survey focused on frequency of foods, categorized by putative cariogenicity, would differentiate severe ECC (S-ECC) from caries-free children. Children's diets were obtained by survey and plaque bacteria detected by PCR from 72 S-ECC and 38 caries-free children. S-ECC children had higher scores for between-meal juice (p < 0.01), solid-retentive foods (p < 0.001), eating frequency (p < 0.005), and estimated food cariogenicity (p < 0.0001) than caries-free children. S-ECC children with lesion recurrence ate fewer putative caries-protective foods than children without new lesions. Streptococcus mutans (p < 0.005), Streptococcus sobrinus (p < 0.005), and Bifidobacteria (p < 0.0001) were associated with S-ECC, and S. mutans with S. sobrinus was associated with lesion recurrence (p < 0.05). S. mutans-positive children had higher food cariogenicity scores. Food frequency, putative cariogenicity, and S. mutans were associated with S-ECC individually and in combination.

Bilateral slipped capital femoral epiphysis: a case report and review of literature

Slipped capital femoral epiphysis (SCFE) is a common adolescent problem in the western populations but it is extremely rare in the Asian regions. We report a case management of a teen age boy (16 years old at the time of operation) with bilateral SCFE. After fall injury, the boy sustained SCFE on the left side and was treated. Again after six months with trivial injury he got SCFE on the right side. In both cases the boy was managed by closed reduction and percutaneous cannulated cancelleous screws fixation under c-arm fluoroscopy control. The cannulated screws were removed after one year of insertion confirming of a good fusion in plain x-ray films. During the regular follow up of up to one year the patient had good hip functions and other daily activities. The patient lost to follow up for about three years and suddenly presented to us with restricted hip joints movements and other activities. The x-ray showed tilted pelvis, reduced, incongruent hip joint spaces with malunited femoral physis, widened neck and tilted femoral head along with visible physeal scan on both sides. The patient and patient party are still satisfied with these results and reluctant to go for further surgical intervention.

Differential bioleaching of copper by mesophilic and moderately thermophilic acidophilic consortium enriched from same copper mine water sample

Three acidophilic enrichment consortium were developed from mine water sample of copper mine site at Khetri, India were compared for their copper leaching efficiency. Out of these one was mesophilic (35 degrees C) and two were moderately thermophilic (50 degrees C). Consortia were named as mesophilic acidophilic chemolithotrophic consortia (MACC), thermophilic acidophilic chemolithotrophic consortia (TACC), and Sulfobacillus acidophilic consortia (SAC). Copper extraction ability of both the thermophilic consortia (77-78% extraction) was almost double to that of mesophilic consortia (40% extraction) at 10% pulp density after 55 days. Both the thermophilic consortia were equally effective in leaching of other metals like Ni, Co, Zn, Mn. After 55 days, the percentage of extractions of copper by TACC was 76, 74, 67, 48 and 45 at 5%, 10%, 15%, 20% and 30% pulp density, respectively. Total number of bacteria was maximum at 5% pulp density which decreases with increase in pulp density. Sulfobacillus-like bacteria were seen in the Sulfobacillus enrichment cultures. Moderately thermophilic consortia proved to be better in leaching performance than the mesophilic counterpart.

Observation of a possible tetrahedratic phase in a bent-core liquid crystal

An experimental study of the heat capacity, mass density, magnetic-field-induced optical birefringence, linewidth and intensity of scattered light, and the viscosities associated with nematic order parameter fluctuations and fluid flow has been performed on an achiral bent-core liquid crystal above its clearing point temperature. The measurements reveal a transition between two optically isotropic phases that is consistent with recent theoretical predictions of a "tetrahedratic" form of orientational order.

The influence of postoperative coronal alignment on revision surgery in total knee arthroplasty

This study examines the association between postoperative coronal tibiofemoral alignment and revision surgery in knee arthroplasty. We retrospectively reviewed the case notes and post-operative long-leg radiographs of 197 Kinemax knee arthroplasty with mean follow-up of 9 years (SD 2.2). They were divided into three groups: neutral, valgus and varus. Revision or decision to revise was used as a hard endpoint. There was no statistical difference among the three groups (p=0.78). We conclude that aseptic failure of a total knee is multifactorial. Coronal tibio-femoral alignment may not be as important a cause of failure as has been previously thought.

Beneficiation of iron ore slime using Aspergillus niger and Bacillus circulans

Studies were carried out on the removal of alumina from iron ore slime containing (%) Fe(2)O(3) 75.7, Al(2)O(3) 9.95, SiO(2) 6.1, Fe (total) 52.94 with the help of Bacillus circulans and Aspergillus niger. B. circulans and A. niger showed 39% and 38% alumina removal after six and 15 days of in situ leaching at 10% pulp density, respectively. Culture filtrate leaching with A. niger removed 20% alumina at 2% pulp density with 13 day old culture filtrate. B. circulans was more efficient than A. niger for selective removal of alumina. In case of A. niger in situ leaching rather than culture filtrate leaching was found to be more effective.

Primary total knee replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register

INTRODUCTION

In 1999, a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Association for Surgery of the Knee (BASK) to provide a basis for regional and national auditable standards: we have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.

MATERIALS AND METHODS

A direct comparison of data held on the North West Hip Arthroplasty Register for 2001/2002 and BASK/BOA guidelines was performed. 86 surgeons from 26 hospitals were included in the study.

RESULTS

A mean of 93.3% of operations were performed in the surgeon's usual theatre. All of these theatres had vertical laminar air flow systems. 42.2% of respondents routinely used exhaust suits and 68.1% of respondents routinely used impermeable disposable gowns. All surgeons use some form of anti-thromboembolic prophylaxis; 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin. 93.7% of surgeons routinely use antibiotic-loaded cement. The PFC and Kinemax prostheses were the most commonly used prostheses. Interestingly, 97.7% of all first-choice implants were cemented. Only 2 surgeons used uncemented total knee replacement. 69.8% of surgeons used a posterior cruciate retaining design. A midline longitudinal skin incision is used by 87.2% of surgeons, a medial longitudinal skin incision by 7.0% and a lateral longitudinal skin incision by 5.8% of surgeons. A medial parapatellar capsular incision is preferred by 91.9% with the remainder using mid vastus or trivector retaining capsulotomy. Closure of capsulotomies is performed in flexion by 65.1% and in extension by 34.9%. In patients with osteoarthritis, 38.4% routinely resurfaced the patella, 34.9% never resurfaced the patella and 26.7% selectively resurfaced. This was in direct contrast to practice for patients with rheumatoid arthritis in whom 66.3% routinely resurfaced the patella, 22.1% never resurfaced the patella and 11.6% selectively resurfaced.

DISCUSSION AND CONCLUSIONS

This study has demonstrated variation of practice in hip arthroplasty across the North West region and significant divergence from the BASK/BOA statement of best practice. The introduction of a properly funded national arthroplasty register will surely help to clarify the effect of such diverse practice on patient outcome.