Primary Hepatic Ectopic Pregnancy: Diagnosis and Laparoscopic Management

OBJECTIVE

To demonstrate and discuss a case of primary hepatic ectopic pregnancy and laparoscopic management.

DESIGN

Case presentation with demonstration of surgical hepatic wedge resection.

SETTING

Tertiary referral center in Manchester, United Kingdom.

INTERVENTIONS

A 33-year-old women gravida 13 para 2 with a body mass index of 55 kg/m2 and previous 2 cesarean sections and a laparoscopic cholecystectomy presented to the emergency services after a private ultrasound scan showing a pregnancy of unknown location and a serum human chorionic gonadotropin (hCG) of 18 336 IU/mL. A diagnostic laparoscopy was performed but fallopian tubes were normal with no signs of ectopic pregnancy seen. An abdominal ultrasound scan was performed but did not identify the ectopic pregnancy. Owing to worsening symptoms of pain and rising hCG levels, she underwent a further laparoscopy converted to laparotomy and a left salpingo-oophorectomy for suspected left ovarian pregnancy. However, serum hCG levels continued to rise after the surgery, reaching 36 960 IU/mL. An magnetic resonance imaging scan of her abdomen and pelvis was arranged that showed a 4 cm cystic lesion in the segment V of the liver. Further ultrasound correlation showed a hyperechoic lesion with echogenic components suspicious of an ectopic pregnancy with a fetal pole. Fetal heart action was not visualized. A multidisciplinary team approach was adopted with involvement of the hepatobiliary surgical team, and the option of medical management with methotrexate and surgical excision was considered. A decision was made for surgical excision based on the accessible location of the ectopic pregnancy on segment V and the more controlled and predictable outcome with surgical excision. A preoperative computed tomography scan confirmed the lesion in segment V of liver in keeping with liver capsular implantation of ectopic pregnancy (Video still 1). At laparoscopy the ectopic pregnancy was visualized on the inferior surface of liver close to the inferior margin with a band of overlying omental adhesion (Video still 2). The overlying omental adhesions were sealed and cut with advanced bipolar diathermy, keeping a safe margin from the ectopic pregnancy to minimize any bleeding. The liver capsule was then opened with monopolar diathermy, and the small segment of liver with the ectopic pregnancy was excised using a combination of Bowa-Lotus liver blade (Bowa Medical Ltd). Hemostasis was controlled using Floseal hemostatic matrix and applied pressure laparoscopically. Total operating time was 80 minutes with an estimated blood loss of 500 mL. The patient was discharged on day 3 postoperatively, and follow-up serum hCG excluded residual trophoblastic disease. On review of the clinical case, earlier imaging of the upper abdomen when confronted by a persistent pregnancy of unknown location with high levels of serum hCG would have prevented the second laparoscopy, laparotomy, and salpingo-oophorectomy. In similar cases, it would also help exclude poorly differentiated malignancies as a source of serum hCG.

CONCLUSION

Only 27 cases of ectopic pregnancy on the liver have been identified in English literature since 1952, based on a MEDLINE and Embase enquiry and further review of all case reports by the authors to avoid duplicates. Estimated incidence of hepatic implantation is 1 in 15 000 pregnancies; 4 case reports of laparoscopic liver resection have been identified and another case managed by suction from the liver surface [1,2]. The key principle demonstrated is to resect the ectopic pregnancy with a safe margin of liver tissue and any adhesions to avoid catastrophic bleeding from direct handling of the ectopic pregnancy.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Impelling Factors for Contracting COVID-19 Among Surgical Professionals During the Pandemic: A Multinational Cohort Study

Background

Medical workers, including surgical professionals working in coronavirus disease 2019 (COVID-19) treating hospitals, were under enormous stress during the pandemic. This global study investigated factors endowing COVID-19 amongst surgical professionals and students.

Methods

This global cross-sectional survey was made live on February 18, 2021 and closed for analysis on March 13, 2021. It was freely shared on social and scientific media platforms and was sent via email groups and circulated through a personal network of authors. Chi-square test for independence, and binary logistic regression analysis were carried out on determining predictors of surgical professionals contracting COVID-19.

Results

This survey captured the response of 520 surgical professionals from 66 countries. Of the professionals, 92.5% (481/520) reported practising in hospitals managing COVID-19 patients. More than one-fourth (25.6%) of the respondents (133/520) reported suffering from COVID-19 which was more frequent in surgical professionals practising in public sector healthcare institutions (P = 0.001). Thirty-seven percent of those who reported never contracting COVID-19 (139/376) reported being still asked to practice self-isolation and wear a shield without the diagnosis (P = 0.001). Of those who did not contract COVID-19, 75.7% (283/376) were vaccinated (P < 0.001). Surgical professionals undergoing practice in the private sector (odds ratio (OR): 0.33; 95% confidence interval (CI): 0.14 - 0.77; P = 0.011) and receiving two doses of vaccine (OR: 0.55; 95% CI: 0.32 - 0.95; P = 0.031) were identified to enjoy decreased odds of contracting COVID-19. Only 6.9% of those who reported not contracting COVID-19 (26/376) were calculated to have the highest "overall composite level of harm" score (P < 0.001).

Conclusions

High prevalence of respondents got COVID-19, which was more frequent in participants working in public sector hospitals. Those who reported contracting COVID-19 were calculated to have the highest level of harm score. Self-isolation or shield, getting two doses of vaccines decreases the odds of contracting COVID-19.

BS P04 Global Level of Harm experienced by Bariatric Surgeons for Bariatrics surgical interventions: An exploration of predictors

Background

COVID-19 pandemic has taken the world by surprise with the depth and breadth of its effect on all walks of life, bariatric surgery being no exception. With the scientific literature hitherto unable to comment and ascertain the influence of the COVID-19 pandemic on bariatric surgery and the level of harm experienced by bariatric surgeons, we- TUGS ‘Level of Harm’ collaborative group- attempted to gauge the effect of the said pandemic on bariatrics surgery specifically vis a vis the level of harm experienced by bariatric surgeons due to the pandemic.

Methods

A virtual questionnaire- developed on both: Google forms and Survey Monkey- was circulated via TUGS social media platforms to reach bariatric consultant surgeons, fellows and residents practising throughout the world in a bid to explore the influence of the COVID-19 pandemic on their surgical practice including but not limited to the annual surgical volume including re-do surgeries volume and postoperative complications. Moreover, they were also requested to categorise their respective level of harm vis a vis bariatric surgical interventions they undertake. After de-identification of the data, SPSS (V.26) was adopted to undergo statistical analysis. After exploring the dataset by descriptive analyses, the Chi-square test was applied to pursue the association of categorical variables with the reported level of harm. A double-sided p-value of less than 0.05 was considered statistically significant.

Results

16.8% of the respondents (21/125) indicated no harm vis a vis bariatrics surgery work whereas a comparative 18.4% of the respondents (23/125) reported moderate harm with significant worsening of symptoms. None of those who indicated less than 10% increase in surgery waitlisted patients being subjected to endoscopic interventions (0/14) reported Moderate Harm for bariatrics surgery work with significant worsening of symptoms whereas 1 in every 3 of those who indicated between 10% to 25% increase in surgery waitlisted patients being subjected to endoscopic interventions (5/15) reported such level of harm for bariatrics surgery work. (p &lt; 0.001) Upon exhaustive sub-group analysis, it was uncovered that 33.6% of bariatrics surgical professionals perceived no harm (no evidence of change in clinical condition) during gastric band or related surgery work with only 4% perceiving Moderate Harm (significant worsening of symptoms/ comorbidities control/ minor increase in medications) for such surgical interventions. All of those who reported No harm for gastric band or related surgical work reported that Single anastomosis duodeno–ileal bypass (SADI-S) accounts for 10% of their practice whereas none of those who indicated that SADI-S accounts for more than 10% of their practice reported No harm for such surgical work. (p = 0.019)

Conclusions

The global snapshot illustrates a trend of low harm vis a vis bariatrics surgery work in surgical professionals practising in the private sector with a lesser number of patients developing COVID-19 postoperatively and no postoperative COVID-19 related mortality. The patient being subjected to endoscopic intervention portends a higher level of harm for bariatrics surgical work- strict adherence to criteria and safety protocols being a logical inference. For gastric band and related surgery work, preoperative COVID-19 testing appears to be influenced by confounders in its effect on the surgeon's level of harm for the said interventions warranting further exploration. SADI-S, at a cut-off of 10%, exhibits strong interaction with the surgeon's level of harm for gastric band insertion and relation surgery work. Women surgical professionals came out to exhibit equivalent mental resilience and technical prowess at par with their male colleagues when it came to bariatrics surgical intervention.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study

BACKGROUND

Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health.

METHODS

We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level of harm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score.

RESULTS

A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%) were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively.

CONCLUSION

Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

Operative versus non-operative management of adhesive small bowel obstruction: A systematic review and meta-analysis

OBJECTIVES

To investigate outcomes of operative and non-operative management of adhesive small bowel obstruction (SBO).

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of operative versus non-operative management of patients with adhesive SBO. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We found one RCT, two prospective and three retrospective observational studies, enrolling a total of 876 patients. The analyses showed that operative management of adhesive SBO was associated with a lower risk of future recurrence [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.38-0.76, P = 0.0005] but a higher risk of mortality [risk difference (RD) 0.03, 95% CI 0.01-0.06, P = 0.01] and complications (OR 5.39, 95% CI 2.97-9.78, P < 0.00001). There was no difference in need for surgical re-intervention rate (OR 0.72, 95% CI 0.35-1.47, P = 0.36) and length of stay [mean difference (MD) 5.07, 95% CI -2.36-12.49, P = 1.0] between operative and non-operative managements. The baseline suspicion of strangulation was a major confounding factor. When the baseline suspicion of strangulation was higher in the operative group, the risk of mortality (RD 0.04, 95% CI 0.02-0.07, P = 0.0006) and complications (OR 8.14, 95% CI 4.16-15.94, P = 0.00001) were higher in the operative group but the risk of recurrence was lower (OR 0.62, 95% CI 0.43-0.90, P = 0.01). When the baseline suspicion of strangulation was low in both groups, there was no difference in any of the outcomes except recurrence (OR 0.09, 95% CI 0.02-0.37, P = 0.0009) which was lower in the operative group.

CONCLUSIONS

The difference in baseline suspicion of strangulation between operative and non-operative groups is a major confounding factor in current literature. The benefit of surgical treatment should be balanced with the risks associated with surgery, patient's co-morbidities, and presence or absence of strangulation. Based on the best available evidence it could be argued that surgical intervention could be preserved for cases with high suspicion or evidence of bowel strangulation. The controversy still remains for optimum length of conservative management and timing of surgery (early or late) for cases with low baseline suspicion of strangulation. Randomised controlled trials are required to compare outcomes of early operation (<24 h) versus late operation (>24 h) and early operation versus conservative management in patients with low suspicion of strangulation.

trans-4,4'-Dihydroxystilbene (DHS) protects PC12 cells from oxidative damage but induces reactive oxygen species-mediated apoptosis in SHSY-5Y cell line

Polyphenols can exert both, antioxidant and pro-oxidant properties, depending on cell types as well as their concentrations. Hence, it was of interest to examine if the naturally occurring resveratrol analog, trans-4,4'-dihydroxystilbene (DHS) also exert both these activities in a biphasic or cell-specific manner. In this study, we established the cytoprotective action of DHS against hydrogen peroxide (H2O2)-induced apoptotic death of the PC12 cells. DHS reduced mitochondrial membrane permeabilization and deactivated reactive oxygen species (ROS)-mediated caspase-3 activation in the H2O2-treated PC12 cells. However, it induced apoptosis in the human neuroblastoma SHSY-5Y cell line by destabilizing mitochondrial membrane, augmenting ROS and activating caspapse-3. DHS showed better activity than resveratrol in both the chosen models.

Association of Oxidative Stress and Obesity with Insulin Resistance in Type 2 Diabetes Mellitus

Oxidative stress occurs due to delicate imbalance between pro-oxidant and anti oxidant forces in our system. It has been found to be associated with many morbidities but its association with obesity and insulin resistance is still controversial. Here in our study we examined 167 patients of recent onset type 2 diabetes mellitus and 60 age sex matched non-diabetic control. Body Mass Index (BMI), abdominal circumference, fasting blood glucose, serum insulin and plasma Malondealdehyde (MDA, marker for oxidative stress) were measured in them. On the basis of BMI, subjects were divided into obese (BMI≥25) and non obese (BMI<25) groups. Insulin resistance scores were calculated by Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) method. Physical parameters (BMI, abdominal circumference) as well as levels of insulin and MDA were found to be significantly higher in subjects with diabetes than their non diabetic controls. The said parameters also showed significant difference in obese and non-obese sub groups. Insulin resistance score showed positive correlation with BMI, abdominal circumference, and plasma MDA, strength of association being highest with abdominal circumference. Plasma MDA was found to have positive correlation with physical parameters. Study concludes that, obesity mainly central type may predispose to insulin resistance and oxidative stress may be a crucial factor in its pathogenesis. Thus, oxidative stress may be the connecting link between obesity and type 2 diabetes mellitus, two on going global epidemics.

Peste des petits ruminants vaccine and vaccination in India: sharing experience with disease endemic countries

Peste des petits ruminants, a viral disease of small ruminants, the control of which is important for poverty alleviation and to ensure livelihood security in Asia, Middle East and Africa. In recognition of these issues, we developed and applied vaccine and diagnostics to demonstrate effective control of PPR during preceding 6 years in a sub-population of small ruminants in India. Two south Indian states, namely Andhra Pradesh and Karnataka, strongly indicated possibility of PPR control with more than 90 % reduction in number of reported outbreaks of PPR, mostly through mass vaccination. Similarly, the situation at the national level also demonstrated a decline of more than 75 % in the number of reported outbreaks. Sharing these experiences may motivate other countries for similar initiatives leading to progressive control of PPR, which is in line with the initiatives of the organizations like FAO/OIE and the recent platforms on global PPR research alliance.

Retroperitoneal Sarcoma. Outcome Analysis in a Teaching Hospital in Eastern India- a Perspective

Primary Retroperitoneal Sarcomas are relatively uncommon tumors with varied manifestations, ill-defined prognostic factors and uncertain management modalities. We undertook this study to review patients who presented with primary or recurrent RPS at our institute during the study period. Between 2008 and 2010, 23 patients were evaluated. Statistical analysis was done using the chi square test or Fisher's exact test. Recurrence was calculated using Kaplan Meier curves. The log-rank test was used to compare differences in survival or relapse. Among the 23 patients, 13 were males. Majority (52.2 %) presented with abdominal lump located in umbilical and right hypochondrial region. Surgery was done in 20 (87 %) patients for primary RPS and three (13 %) for recurrent RPS at initial presentation. 14 (61 %) received complete tumor resection, six (27 %) incomplete microscopic resection, and three (13 %) incomplete macroscopic resection. In univariate Cox's proportional hazard model on time ('timer') to event ('relapse') analysis, all the variables like older age (p = 0.027), male sex (p = 0.012), incomplete resection (p = 0.008), large size (0.047) and high grade (p = 0.047) became significant predictor of early recurrence. However, multivariate analysis showed that only extent of resection, grade and sex were statistically significant predictors. Complete tumor resection of retroperitoneal sarcoma (n = 14) was associated with a significantly lesser recurrence compared with unclear resection (n = 9, p = 0.002). The median time between surgery and first recurrence was 15 months. High-grade sarcomas had a significantly higher recurrence (n = 10; median: 24, 95 % CI) than low-grade sarcomas (n = 13, median: 15; 95 %CI P < 0.01). Furthermore, the survival of male patients were worse than that of females (p = 0.036). Completeness of resection, tumor grade and sex are prognostic factors of retroperitoneal soft tissue sarcomas.

Cutaneous malignant and premalignant conditions caused by chronic arsenicosis from contaminated ground water consumption: a profile of patients from eastern India

Natural arsenic pollution is a major global health problem. The two worst affected areas e Bangladesh and West Bengal, India. Arsenic is a well-documented human carcinogen that affects many organs including the skin. The authors sought to find out the clinical patterns of different malignant and premalignant conditions associated with chronic arsenicosis from drinking contaminated ground water in a group of patients from eastern India. This was a clinical observational study. Patients with chronic arsenicoses with suspected cutaneous malignancies for whom dermatology service was sought were enrolled in the study. A total of 24 patients (male to female ratio, 11:1; age range, 32-71 years; mean age, 52.2 years) were evaluated. Squamous cell carcinoma (SCC) was the commonest malignancies in our series, seen in 10 (41.7%) patients. This was followed by Bowen's disease (9 [37.5%]) and basal cell carcinoma (8 [33.3%]). Three patients (12.5%) had > 1 type of cutaneous malignancies. Multicentric lesions were seen in 3 cases. The most common site of involvement was the chest (8 [33.3%]). No statistically significant correlation was found between number of lesions and arsenic content in the hairs and nails of the patients.

Primary cutaneous precursor B-cell lymphoblastic lymphoma with late dissemination

A 20-year-old woman presented with multiple painless nodular swellings on the skin of the extremities and face, without any systemic symptoms. Biopsy with immunohistochemistry revealed a diagnosis of precursor B-cell lymphoblastic lymphoma. There was no extracutaneous site of involvement. The patient denied chemotherapy and was subsequently lost to follow-up. She presented with symptomatic disseminated disease 18 months later and rapidly succumbed to her illness.

Antegrade common bile duct (CBD) stenting after laparoscopic CBD exploration

Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and cost-effective treatment for choledocholithiasis. Following LCBDE, the clearance may be ascertained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in situ or may be drained by means of a T-tube or a biliary enteric anastomosis.

Torsion of the epiploic appendix: An unusual cause of acute abdomen

SUMMARY

Torsion of an epiploic appendix is a rare surgical entity. We present our experience in a thirty five year old female patient and a forty year old male patient.

MATERIALS AND METHODS

A 35 year old lady had presented with right iliac fossa pain of 2 days duration. Guarding and rebound tenderness was present over the area. Investigations showed mild leucocytosis and neutrophilia. Diagnostic laparoscopy revealed an inflamed epiploic appendix which was excised. Other intrabdominal organs were normal. A 40 year old male patient had presented with a history of recurrent, colicky, and paroxysmal right lower quadrant pain for 2 months. At laparoscopy, an inflamed torted epiploic appendix of the ascending colon was detected and excised. Other intrabdominal organs were normal.

RESULTS

Both the patients had an uneventful recovery and are asymptomatic at follow up of 10 and 7 months respectively. They have been followed up at 7 days, 4 wks and then 3 monthly.

DISCUSSION

The clinical presentation of an inflamed appendices epiploicae may be confusing. CT is helpful in disgnosis. Laparoscopy may be used to diagnose and treat the condition as well.

CONCLUSION

Diagnostic laparoscopy is an useful tool for surgeons in assessing abdominal pain where the cause is elusive. It may be used to diagnose and treat torsion of an epiploic appendix effectively.

Mitochondrial medicine

Mitochondrial diseases are extremely heterogeneous multisystem disorders predominantly affecting tissues or organs with high oxygen consumption like skeletal muscles, brain, endocrine glands, myocardium, eyes, ears, intestines, liver, kidneys, and bone marrow. Although various clinical syndromes have been described, they frequently overlap and there is no diagnostic gold standard to identify all. It is difficult to chart the future of an affected individual as also to predict the response to treatment which is mostly supportive and symptomatic. The rapidly increasing understanding of the pathophysiologic background of mitochondrial disorders may facilitate diagnostic approach and open perspectives to curative therapies. With the coming of age for mitochondrial medicine, it is now appropriate that physicians keep themselves well-acquainted with the recent developments in this expanding field of biomedical research.

Familial hypoparathyroidism

A family with hereditary (familial) hypoparathyroidism is reported where three of the total four siblings were affected and each presented with different manifestation-one brother with refractory epilepsy since early childhood, another brother with unilateral extrapyramidal features in adult life, and their only sister having recurrent attacks of tingling and numbness due to hypocalcemia since 12 years of age.

Pro-ulcer effects of resveratrol in mice with indomethacin-induced gastric ulcers are reversed by L-arginine

BACKGROUND AND PURPOSE

Although resveratrol is currently being evaluated in pre-clinical studies as a potential cancer chemopreventive agent and cardiovascular stress-releasing compound, treatment with resveratrol severely delays healing of pre-existing gastric ulcers. Resveratrol treatment can also induce endothelial NOS (eNOS) expression. Here, we have attempted to modulate NO production via eNOS in order to alleviate the pro-ulcer effects of resveratrol.

EXPERIMENTAL APPROACH

Gastric ulcers were induced in mice with a single dose of indomethacin. The effects of pretreatment with l-arginine on the pro-ulcer effects of resveratrol in these mice were then assessed. We measured ulcer damage scores (DS), myeloperoxidase (MPO) activity, generation of prostaglandin E(2) (PGE(2)) and NO, along with a gene expression study.

KEY RESULTS

Resveratrol significantly aggravated damage from indomethacin-induced gastric ulcers, and delayed healing, as shown by increased DS and MPO activity. The mRNA for cyclooxygenase (COX)-1, but not that for COX-2, was inhibited by resveratrol treatment, with reduced synthesis of PGE(2) by gastric tissue. However, resveratrol treatment induced eNOS gene expression and shifted the eNOS/iNOS balance. l-Arginine given before resveratrol in mice with indomethacin-induced ulcers significantly increased tissue NO synthesis and improved ulcer healing.

CONCLUSIONS AND IMPLICATIONS

Exogenous l-arginine increased NO formation via raised levels of eNOS induced by resveratrol and protected against the pro-ulcer effects of resveratrol. Therefore, l-arginine might be useful for alleviation of the pro-ulcer side effects of resveratrol in patients.

Profile of tuberculous meningitis with or without HIV infection and the predicators of adverse outcome

OBJECTIVES

To compare the clinical, radiological and cerebrospinal fluid (CSF) findings, at hospital admission, among adult patients with tuberculous meningitis (TBM) with or without HIV infection and to identify the factors that predict adverse outcome at six months.

METHODS

A total of 82 adult patients with TBM were included (40 HIV-positive and 42 HIV-negative). Several clinical (duration of illness, Glasgow Coma Scale score, presence of high temperature, headache, cranial nerve or sphincter abnormality, seizures and endocrine dysfunction), radiological (presence of hydrocephalus, cerebral infarction and oedema, meningeal enhancement, granuloma) and cerebrospinal fluid parameters (glucose, protein, lactate, lymphocytes, neutrophils and adenosine deaminase values) were recorded along with CD4 count in the peripheral blood. Statistical analysis was performed using the chi-square test. Individual variables were evaluated as prognostic factors for adverse outcome in both groups by calculating the relative risk of association for each.

RESULTS

Temperature more than 38.33 degrees C was more common in the HIV-negative group while seizures, hydrocephalus, cerebral infarction and low CD4 count occurred significantly more commonly in the HIV-positive group. Hydrocephalus had strong association with severe neurological deficit and seizure with death in both the groups.

CONCLUSION

Several clinical and laboratory features of TBM in patients who are HIV-positive are distinctly different from those without HIV infection; some of these have an association with the probability of adverse outcome.

Plasma levels of lipid peroxides in patients with Parkinson's disease

Oxidative stress is implicated as a major factor for nigral neuronal cell death. Metabolic failure in antioxidant mechanisms could hypothetically facilitate the chemical processes that lead to lipid peroxidation. To elucidate whether elevated lipid peroxidation rates might increase risk of developing Parkinson's disease (PD), the Authors determined plasma levels of malondialdehyde (MDA) in 80 PD patients and 80 controls. There was a significant difference between the plasma MDA levels of PD patients and controls (7.48 +/- 1.55 vs 5.1 +/- 1.26 nmol/ml). Plasma MDA levels were inversely related to the age of the PD patients (r = -0.46; p < 0.01) and age of onset but in the control group, no such correlation was observed between the plasma MDA and age. However, there was no significant correlation between plasma MDA levels and the duration of disease, Hoehn and Yahr stages and the Unified Parkinson's Disease Rating Scale (UPDRS). Thus, the results suggest that high plasma lipid peroxidation rates might contribute as a risk factor for PD in West Bengal.

Regulation of the nitric oxide synthesis pathway and cytokine balance contributes to the healing action of Myristica malabarica against indomethacin-induced gastric ulceration in mice

The role of the ariginine-metabolism in the healing action of the methanol extract of Myristica malabarica (rampatri) (RM) and omeprazole (Omez) against indomethacin-induced stomach ulceration in mouse was investigated. Indomethacin (18 mg/kg) was found to induce maximum stomach ulceration in Swiss albino mice on the 3rd day of its administration, which was associated with reduced arginase activity (38.5%, p < 0.05), eNOS expression, along with increased iNOS expression, total NOS activity (5.37 fold, p < 0.001), NO generation (55.1%, p < 0.01), and ratio of pro-/anti-inflammatory cytokines. Besides providing comparable healing as Omez (3 mg/kg × 3 d), RM (40 mg/kg × 3 d, p.o.) shifted the iNOS/NO axis to the arginase/polyamine axis as revealed from the increased arginase activity (59.5%, p < 0.01), eNOS expression, and reduced iNOS expression, total NOS activity (73%, p < 0.001), and NO level (49.8%, p < 0.01). These could be attributed to a favourable anti/pro inflammatory cytokines ratio, generated by RM. The healing by Omez was however, not significantly associated with those parameters.

Massive haemothorax: a presentation of pulmonary arteriovenous malformation

Arteriovenous malformations of the lung are relatively uncommon lesions with varied clinical presentation. Nearly half of these are associated with Osler-Rendu-Weber disease. Magnetic resonance angiography is an accurate and non-invasive diagnostic modality. We report a case of a 56-year-old male who had massive haemothorax due to rupture of a pulmonary arteriovenous malformation arising from the right interlobar artery.

Rapid quality control of a live attenuated Peste des petits ruminants (PPR) vaccine by monoclonal antibody based sandwich ELISA

Peste des petits ruminants (PPR) is a highly contagious and economically important viral disease of goats and sheep. A homologous Vero cell-based attenuated PPR vaccine developed in our laboratory and used extensively throughout the country, is available for control of PPR. The presently used quality control test, titration in Vero cells for PPR virus titre in vaccine batches, takes at least 6-8days to determine the quality and dose of vaccine. In this study, 74 freeze-dried PPR vaccine batches were tested simultaneously by both virus titration and PPR sandwich ELISA (S-ELISA) to correlate the titre of the vaccine virus with reactivity in S-ELISA. It was found that the vaccine batches with titre more than 10(3)TCID(50)/ml gave positive results in S-ELISA and correlated well with the virus titre of the freeze-dried vaccines. The correlation coefficient between the virus titration and S-ELISA reactivity was estimated as 0.96, indicating a high correlation between the two parameters based on 74 batches of freeze-dried PPR vaccine. The vaccine batches with titres of 3.0, 4.3, 4.5, 5.0, 6.5 and 7.0 had shown a positive reaction when tested in two-fold dilutions in S-ELISA at 1, 5, 6, 7, 8 and 9log2 titres, respectively. The test vaccine batches were found to be negative in S-ELISA when the titre of the vaccine was less than 10(3)TCID50/ml, suggesting that the vaccine could not be passed for field use. It is concluded that S-ELISA could be a preliminary tool useful for the quality control of PPR vaccine as it is rapid and easy to perform when compared to virus titration.

Sequence analysis of the nucleoprotein gene of Asian lineage peste des petits ruminants vaccine virus

The complete nucleotide sequence of the nucleocapsid (N) protein of the peste-des-petits ruminants vaccine virus (PPRV Sungri/96) belonging to the Asian lineage was determined. The gene was 1692 nucleotides in length and encoded a polypeptide of 525 amino acids. The PPRV Sungri/96 N gene has a nucleotide homology of 92% for PPRV Nigeria 75/1 to 55.5% for canine distemper virus. At amino acid level the homology was 94.1% with PPRV Nigeria 75/1, while with other morbilliviruses, PPRV Sungri/96 had only 71.4-64.9% amino acid identity. The phosphorylation prediction reveals eight conserved sites across morbilliviruses, whereas in the C-terminal portion of the protein the sites are not conserved. Phylogenetic analysis of different N proteins of morbilliviruses revealed five well-defined clusters as observed previously. To the best of our knowledge this is the first report describing the nucleocapsid gene sequence of PPRV Indian isolate.

Primary duodenal lymphoma producing obstructive jaundice

Primary lymphoma of the duodenum presenting with obstructive jaundice is a rare entity. We report a case of primary non-Hodgkin's lymphoma of the duodenum producing obstructive jaundice in a middle aged lady, where the concentric thickening of the duodenal wall also gave rise to symptomatic partial high small bowel obstruction in due course. Guided aspiration and flowcytometry established a diagnosis of diffuse large B-cell lymphoma.

One-step multiplex RT-PCR assay for the detection of peste des petits ruminants virus in clinical samples

A single-tube one-step multiplex RT-PCR was standardized to amplify both 337 bp and 191 bp fragments of N and M genes of peste des petits ruminants virus (PPRV), respectively, and only a 337 bp fragment of N gene of Rinderpest virus (RPV). The RT-PCR using purified viral RNA was easily adopted for direct detection of PPRV in clinical field samples and its differentiation from RPV. The amplified N and M gene products were confirmed to be PPRV- and RPV-specific by their size in 1.5% agarose gel and restriction analysis. In the assay, the Qiagen one-step RT-PCR kit containing the Ominiscript and Sensiscript reverse transcriptases and Hot star Taq DNA polymerase was utilized. The sensitivity of the assay was found to be 100 fg of PPRV RNA. Compared with a two-step assay, the one-step assay is easier and time-saving as it requires just a single buffer for both reactions, reverse transcription (RT) and PCR. In experimentally infected goats, PPRV was detectable by the one-step RT-PCR in nasal and ocular swabs 7-17 days post infection (p.i.). and in oral swabs 7-15 days p.i. Out of 32 clinical field samples tested, 18 were positive by sandwich ELISA (S-ELISA), while 22 were positive by the one-step RT-PCR.

Development and characterization of a stable vero cell line constitutively expressing Peste des petits ruminants virus (PPRV) hemagglutinin protein and its potential use as antigen in enzyme-linked immunosorbent assay for serosurveillance of PPRV

We developed and characterized a stable Vero cell line constitutively expressing Peste des petits ruminants virus (PPRV) hemagglutinin (H) protein and assessed its potential use as diagnostic antigen in enzyme-linked immunosorbent assay (ELISA). PPRV H gene of the vaccine strain (Sungri-96) was amplified by reverse transcription (RT)-PCR, cloned into a eukaryotic expression vector (pTarget), and subsequently transfected and expressed in Vero cells. A stable Vero cell line was developed after 20 repeated passages by using G418 antibiotic selection pressure (400 to 600 microg/ml). The integration of PPRV H gene in the Vero cell genome and its genomic transcription were confirmed by PCR and RT-PCR assays, respectively, and the 70-kDa PPRV H protein was characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting. The recombinant protein reacted specifically with PPRV anti-H neutralizing monoclonal and polyclonal antibody in competitive, sandwich, and indirect ELISA, respectively, indicating that the native form of the protein was expressed. Evaluation of the protein in competitive ELISA and indirect ELISA vis a vis whole virus was done using 306 and 146 goat field serum samples, respectively; comparable results were obtained with high degrees of relative diagnostic specificity (93.53% and 100%, respectively) and sensitivity (99.04% and 79.16%, respectively). This study shows that the PPRV H protein could be a sustainable source of safe antigen in countries of nonendemicity without the need to handle infectious virus for serodiagnosis.

Sequence analysis of the haemagglutinin and fusion protein genes of peste-des-petits ruminants vaccine virus of Indian origin

The amino acid composition of the two surface proteins of peste-des-petits ruminants vaccine virus belonging to lineage four from India were deduced from the nucleotide sequence. The fusion (F) protein gene of PPRV Sungri/96 is 2405 nucleotides long and in relation to the length, it is 80 nucleotides longer than that of PPRV Nigeria/75/1 which are found to be present at the 5'UTR of this virus. The complete F gene alignment with other morbillivirus reveals a homology of 89% with PPRV/Nigeria/75/1 and 48-51% with other morbilliviruses. The F protein of PPRV Sungri/96 exhibited characteristics similarity to those of other morbillivirus F proteins. The overall amino acid similarity with its counterpart PPRV Nigeria/75/1 was 96%; with other morbilliviruses it is 65-74%. The PPRV Sungri/96 haemagglutinin (H) protein gene is 1954 nucleotides long and showed a sequence homology of 90.7% with PPRV/Nigeria/75/1 and with other morbilliviruses it ranged from 33% to 45%. At amino acids level, PPRV Sungri/96 showed a homology of 92.3% with PPRV/Nigeria/75/1 and 34-49% with other morbilliviruses. The phylogenetic tree constructed for F and H gene reveals four separate groups which is very similar to that found in other genes. To the best of our knowledge this is the first report describing the F and H genes of an Indian isolate.

Sequence analysis of VP7 gene of Indian bluetongue virus serotype-23 shows its close phylogenetic relationship to Australian and Chinese serotypes

Bluetongue, an arthropod borne viral disease of wild and domestic ruminants, causes heavy economic losses throughout the world. In the present study, full-length VP7 gene of Indian bluetongue virus (BTV) serotype 23 was sequenced and compared with prototype strains of BTV reported from different countries. Nucleotide sequence analysis of VP7 gene revealed Indian BTV serotype 23 to have 1154 nucleotides with the deletion of two nucleotides at 3' non-coding region and a unique amino acid change 211S-N. The Indian virus also demonstrated a maximum similarity of 94.2% with Australian serotype 1 and a minimum similarity of 67.4% with Australian serotype 15. However, at deduced amino acid level, it had maximum similarity of 99.7% and a minimum of 82.5% with Chinese serotypes 1, 2 and 4 and Australian serotype 15, respectively. Deduced amino acid sequence analysis of putative receptor binding domain (121-249) revealed all the nine hydrophilic domains to be conserved across the serotypes. Functional motifs present in VP7 protein were also conserved in almost all the BTV serotypes including Indian serotype 23. Phylogenetic analysis based on VP7 gene sequence revealed Indian BTV serotype 23 segregating into a monophyletic group along with Australian serotype 1 and Chinese serotypes 1, 2 and 4, indicating its close evolutionary relationship with these Australian and Chinese serotypes.

Sequence analysis of the non-structural 3A and 3C protein-coding regions of foot-and-mouth disease virus serotype Asia1 field isolates from an endemic country

A total of 18 foot-and-mouth disease virus (FMDV) serotype Asia1 field isolates belonging to two different lineages (including the divergent group) as delineated earlier in VP1-based phylogeny were sequenced in the non-structural 3A and 3C protein-coding regions. The phylogenetic trees representing the regions coding for the non-structural proteins were very similar to that of the structural VP1 protein-coding region. Phylogenetic comparison at 3C region revealed clustering of Asia1 viruses with the isolates of serotypes O, A and C in the previously identified clade. Comparison of amino acid sequences identified lineage-specific signature residues in both the non-structural proteins. Overall analysis of the amino acid substitutions revealed that the 3A coding region was more prone to amino acid alterations than 3C region.

Isolated massive thyroid metastasis in lung cancer

Metastasis to the thyroid gland is rare despite its rich vascular supply. Among the pulmonary malignancies metastasising to the thyroid, adenocarcinomas are the commonest. The appearance of metastatic disease in lung carcinoma indicates a poor prognosis and the average survival is two months. We report a 62-year-old woman with squamous cell carcinoma of lung metastatic to the thyroid that produced massive enlargement of the gland. The appearance of the secondary preceded the diagnosis of the primary malignancy by a few months. Ultimately, the patient succumbed to her disease.

Melnick- needles osteodysplasty presenting with quadriparesis

Melnick-Needles syndrome or osteodysplasty, a monogenic heritable bone dysplasia, is characterized by a typical facies and characteristic radiological findings. Less than 70 well-documented cases have been reported in literature; most of them were sporadic. We report the first case from Eastern India in an adolescent male, who had cranio-vertebral junction anomalies and presented with spastic quadriparesis at the age of 13 years.

The M and N genes-based simplex and multiplex PCRs are better than the F or H gene-based simplex PCR for Peste-des-petits-ruminants virus

Nucleocapsid (N), matrix (M) and hemagglutinin (H) genes-based simplex PCRs and an N and M genes-based multiplex PCR were developed for detection of Peste-des-petits-ruminants virus (PPRV). The M gene PCR was the most sensitive, followed by N, H and an already described fusion (F) gene PCRs, as they could detect the virus in samples with titers of 101, 102, 104and 105 TCID50/ml, respectively. The multiplex PCR was as sensitive as the M gene PCR, but it had the advantage of differentiating PPRV from Rinderpest virus (RPV).

A novel genetic lineage differentiating RT-PCR as a useful tool in molecular epidemiology of foot-and-mouth disease in India

Comparison of nucleotide sequences at the VP1 coding region of foot-and-mouth disease serotype Asia1 viruses from India has revealed two genetic lineages with emergence of a genetically divergent group in recent years. In this study a simple, fast, relatively costeffective multi-primer RT-PCR assay to differentiate genetic lineages of type Asia1 viruses was developed. Efforts were made in the design of novel lineage-specific primers and in optimization of the multi-primer assay protocol in conjunction with the use of the serotype specific primer for confirmation of serotype Asia1 virus. This assay promises to be an effective tool in molecular epidemiological investigation of FMD in the country.

Analysis of the matrix protein gene sequence of the Asian lineage of peste-des-petits ruminants vaccine virus

The M gene nucleotide sequence of an Indian peste-des-petits ruminants (PPRV) vaccine virus ("PPRV Sungri/96") belonging to Asian lineage was determined. The gene is 1476 nucleotides long with a single open reading frame (ORF). The nucleotide and predicted amino acid sequence was compared with the homologous region of the African Lineage Vaccine virus "PPRV/Nigeria/75/1". The nucleotide sequence of the "PPRV Sungri/96" was 86% identical to that of "PPRV/Nigeria/75/1", while a homology of 93% and 95% could be observed in the ORF and amino acids level, respectively. The M gene encodes a protein of 335 amino acids, with a predicted molecular weight (MW) of 37.8 kDa. The ORF is flanked by a 3' untranslated region of 436 nucleotides and a high level of sequence divergence (approximately 30%) could be observed in this region between the vaccine viruses of Asian and African lineages. A high degree of conservation of several amino acids of this protein observed previously was also confirmed in this study.

Comparative nucleotide sequence analysis of the phosphoprotein gene of peste des petits ruminants vaccine virus of Indian origin

The nucleotide sequences of the phosphoprotein (P) gene of peste des petits ruminants (PPRV) vaccine virus (PPRV Sungri/96) belongs to Asian lineage have been determined and the deduced amino acid sequences were compared with another vaccine strain PPRV/Nigeria75/1 and with those of the other morbilliviruses. The 1652 nucleotides of the P gene encode a phosphoprotein of 509 amino acid residues (from nucleotide numbers 60 to 1587), which is 91% identical to that of PPRV/Nigeria75/1. The C protein consists of 177 amino acid residues and is 91% identical with that of PPRV/Nigeria75/1. The conserved mRNA editing site (5'TTAAAAGGGCACAG) was present at positions 742-756 in the P gene, which is conserved in all other morbilliviruses. The CTT trinucleotide sequence is present at the N/P and P/M intergenic region, which is totally conserved in morbilliviruses. This will be the third sequence for the P gene of PPRV since that of the vaccine strain and a wild-type Turkish isolate has been published already.

Mitochondrial hepatopathies

Hepatocyte mitochondrion functions as a cause and as a target of liver injury. Since the mitochondria are under dual control of nuclear DNA and mitochondrial DNA (mtDNA), mutations in genes of both classes have been associated with inherited mitochondrial hepatopathies. Point mutations, deletions, insertions, rearrangements, DNA depletion--all have been identified. Many factors influence the prevalence of mitochondrial disorders, including the mutations rate, inheritance pattern, population structure, and the genetic background. In primary disorders, mitochondrial defect is the primary cause of liver disease often producing fatal hepatic failure in infancy or childhood. In secondary disorders, insult to mitochondria is caused by either a gene defect that affects non-mitochondrial proteins or by an exogenous injury to mitochondria. Diagnosis should be suspected in cases of liver disease with neuromuscular symptoms, multisystem involvement that cannot be explained by a single pathology or rapidly progressive liver failure in early childhood. Laboratory findings in the blood and urine show an altered redox status. Various antioxidants, vitamins, cofactors, and electron acceptors have been for proposed but none is effective. Presence of neuromuscular or extraintestinal involvement in primary disorder precludes the use of liver transplantation.

Experimental studies on immunosuppressive effects of peste des petits ruminants (PPR) virus in goats

Effect of virulent and attenuated peste des petits ruminants (PPR) virus on the immune response to nonspecific antigen (ovalbumin) was investigated. Clinical and serological responses were monitored in goats administered with ovalbumin concurrently with either PPR vaccine or virulent virus. Study showed that PPR virulent virus causes marked immunosuppression as evidenced by leukopenia, lymphopenia, and reduced early antibody response to both specific and nonspecific antigen. These observations were predominant particularly during acute phase of disease (4-10 days post-infection). On the other hand, the vaccine virus induced only a transient lymphopenia without significantly affecting the immune response to nonspecific antigen or to itself during this period. Further, the antibody levels to ovalbumin in the group administered with virulent PPRV increased significantly between days 28 and 35 post-infection in comparison to the titers in other two groups given with either ovalbumin alone or in combination with vaccine.