Effect of nutritional-deficiency anemia on peripapillary retinal nerve fiber layer: A North Indian study

PURPOSE

The purpose of this study was to evaluate the effect of nutritional-deficiency anemia (NDA) on peripapillary retinal nerve fiber layer thickness (PPRNFLT) using spectral-domain optical coherence tomography and to determine any correlation arising thereof. This was a single-center, cross-sectional, observational study.

MATERIALS AND METHODS

A total 115 eyes of 115 NDA patients (50 of each with iron-deficiency anemia [IDA] and Vitamin B12-deficiency anemia [BDA], and 15 with folic acid-deficiency anemia [FDA]) aged 18-65 years were compared with a total 100 eyes of 50 age- and sex-matched healthy controls. All subjects underwent comprehensive clinical, ophthalmic, and hematological evaluation, followed by PPRNFLT assessment for the mean total, superior, inferior, nasal, and temporal quadrants.

RESULTS

PPRNFLT for the mean total and all four quadrants in IDA patients, for the mean total, inferior, nasal, and temporal quadrants in BDA patients, and for the mean total, inferior, and nasal quadrants, in FDA patients, was significantly lower as compared to the controls (P < 0.05). The mean total PPRNFLT of all NDA patients correlated significantly (P < 0.05) with their relevant hematological parameters with Pearson's coefficient (r) value of 0.613, 0.610, 0.336, 0.295, 0.337, 0.374, and - 0.509, respectively, for serum haemoglobin (Hb), iron, ferritin, mean corpuscular volume (MCV), mean cell hemoglobin, mean corpuscular hemoglobin concentration, and total iron binding capacity in IDA; 0.310, 0.435, and - 0.386, respectively, for serum Hb%, Vitamin B12, and MCV in BDA; and 0.557, 0.358, and - 0.294 for Hb%, folate, and MCV, respectively, in FDA cases. Mean total retinal nerve fiber layer thinning of all NDA patients showed progression with the increasing severity grades of anemia, except in very severe BDA where an inverse relationship was documented.

CONCLUSION

Our study revealed that PPRNFLT is significantly thinner in all NDA patients (total and all four quadrants in IDA; total, inferior, nasal, and temporal in BDA; and total, inferior, and nasal in FDA) correlating well with their relevant hematological parameters. Early detection of this may be crucial in preventing potential blinding sequelae and differentiating glaucomatous and other neuro-ophthalmic disorders.

Early Impact of Cardiopulmonary Bypass on Renal Function after Valve Replacement Surgery

Renal dysfunction following cardiopulmonary bypass is well recognized. The pathophysiology of renal injury is multifactorial and culmination of the interplay of several pathophysiological mechanism. Cardiac surgery requiring cardiopulmonary bypass (CPB) is being carried out on an extended patient population of different age groups and undergoing complex surgical procedure, and thus it places them at an increased risk of renal impairment. Valve replacement surgery is a major and complex surgical procedure requiring CPB. This study was therefore designed to observe the impact of CPB and short term outcome on patients with reduced estimated Glomerular Filtration Rate (eGFR) (60-89ml/min/1.73m²) after valve replacement surgery. This cross-sectional study was conducted in the Department of Cardiac Surgery, National Institute of Cardio Vascular Diseases (NICVD) during the period of January 2015 to August 2016. After fulfillment of enrollment criteria 100 patients were studied for the purpose of the study and they were grouped in two, patients with normal eGFR (≥90ml/min/1.73m²) in Group A and patients with reduced eGFR (60-89ml/min/1.73m²) in Group B. A total of 100 patients, 50 in each group were studied for renal function alteration after valve replacement surgery under cardiopulmonary bypass. The incidence of Acute Kidney Injury (AKI) was higher in Group B. Chi-square test was done and p value was 0.011 which is statistically significant. Postoperative blood loss (ml/hr) (p=0.038), duration of Intensive Care Unit (ICU) stay (in hours) (p=0.009), postoperative hospital stay (days) (p=0.014) was significantly higher and postoperative Urine Output (ml/hr) (p=0.001) was significantly lower in patients with reduced eGFR (60-89ml/min/1.73m²) in Group B. Deterioration of renal function is more in patient with eGFR (60-89ml/min/1.73m²) after valve replacement surgery under cardiopulmonary bypass in comparison with patients with eGFR (≥90ml/min/1.73m²).

Understanding the role of power and its relationship to the implementation of the polio eradication initiative in india

Background

Power is exercised everywhere in global health, although its presence may be more apparent in some instances than others. Studying power is thus a core concern of researchers and practitioners working in health policy and systems research (HPSR), an interdisciplinary, problem-driven field focused on understanding and strengthening multilevel systems and policies. This paper aims to conduct a power analysis as mobilized by the actors involved in implementation of the polio program. It will also reflect how different power categories are exerted by actors and embedded in strategies to combat program implementation challenges while planning and executing the Global Polio Eradication Initiative.

Methods

We collected quantitative and qualitative data from stakeholders who were part of the Polio universe as a part of Synthesis and Translation of Research and Innovations from the Polio Eradication Project. Key informants were main actors of the polio eradication program, both at the national and sub-national levels. Research tools were designed to explore the challenges, strategies and unintended consequences in implementing the polio eradication program in India. We utilized Moon's expanded typology of power in global governance to analyze the implementation of the polio eradication programme in India.

Results

We collected 517 survey responses and conducted 25 key informant interviews. Understanding power is increasingly recognized as an essential parameter to understand global governance and health. Stakeholders involved during polio program implementation have exerted different kinds of power from structural to discursive, moral power wielded by religious leaders to institutional power, expert power used by professional doctors to commoners like female vaccinators, and network power exercised by community influencers. Hidden power was also demonstrated by powerless actors like children bringing mothers to polio booths.

Conclusion

Power is not a finite resource, and it can be used, shared, or created by stakeholders and networks in multiple ways. Those people who seem to be powerless possess invisible power that can influence decision making. Moreover, these power categories are not mutually exclusive and may be deeply interconnected with each other; one type of power can be transformed into another. Power and relations play an important role in influencing the decision-making of the community and individuals. Mid-range theories of core implementation science like PARIHAS and CFIR can also add an important variable of power in their construct necessary for implementation success of any health program.

Effect of vitamin B12 deficiency anemia on peripapillary retinal nerve fiber layer

AIM

To evaluate the effect of vitamin B12 deficiency anemia (BDA) on peripapillary retinal nerve fiber layer thickness (RNFLT) using spectral domain optical coherence tomography (SD-OCT), and to determine any correlation arising thereof.

METHODS

In this cross-sectional observational study, 99 eyes of 50 BDA patients of age 18-65y were compared with 100 eyes of 50 healthy control subjects. All subjects underwent comprehensive clinical, ophthalmic, and hematological evaluation, followed by peripapillary RNFLT assessment using SD-OCT.

RESULTS

The mean total, inferior, nasal, and temporal RNFLT were significantly lower in BDA group as compared to control group (P<0.05). The mean total, inferior and nasal RNFLT correlated significantly (P<0.05) with serum Hb%, B12 and mean corpuscular volume (MCV) level (r=0.310, 0.435, -0.386 for total; r=0.932, 0.481, -0.513 for inferior; r=0.344, 0.254, -0.233 for nasal; respectively), while temporal and superior RNFLT quadrant did not show any correlation with any of the hematological parameters (r=0.144, 0.167, -0.096; r=0.111, 0.070, -0.099; respectively). The mean total RNFLT showed progressive thinning at par with the progression of anemia, except in very severe BDA, where an inverse relationship was documented.

CONCLUSION

The mean total, inferior, nasal, and temporal peripapillary RNFLT was significantly thinner in BDA patients. Peripapillary RNFLT thinning seemed to proceed at par with the progression of severity of anemia, except in very sever grade. Early assessment of peripapillary RNFLT may be crucial in BDA patients to prevent potential blinding sequelae. Peripapillary RNFLT thinning in BDA patients should be considered in the differential diagnosis of other non-glaucomatous optic neuropathies, as well.

30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation

Introduction

The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.

Methods

We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.

Results

Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.

Conclusion

It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate. 

Long-term outcomes in perianal fistulizing Crohn's disease in a resource-limited setting: A cohort analysis

BACKGROUND

Perianal fistula is one of the most challenging complications of Crohn's disease (CD). We aimed to describe treatment response with surgical and medical therapies, and long-term complications.

METHODS

We retrospectively analyzed records of patients with perianal fistulizing CD who were prospectively followed from January 2005 to December 2018.

RESULTS

Among 807 patients, 81 (10%) had perianal fistula and 65 were included in the final analysis. The mean age of presentation was 27.4 ± 10.3 years, and 78.5% were males with a median duration of follow-up of 45 (IQR, 24-66) months. 75.4% (n = 49) had complex fistulae. 55.4% (n = 36) of patients received multiple courses (> 5 courses) of antibiotics. Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively. The relapse rate was highest after fistula surgery (52.6%). 44.6% of patients received medical (immunomodulators-21 and biologicals-8) whereas 46.1% received surgery as the first-line therapy. The absence of perianal abscess was associated with complete fistula closure. One patient developed malignancy and 4 (6.1%) died at the end of follow-up. Among the patients (n = 28) who received biologicals, TB reactivation occurred in one patient (3.5%).

CONCLUSION

Medical therapy should be offered as first-line therapy, and immunomodulators can be considered when patients cannot afford biologicals. Surgery offers temporary improvement and is associated with high relapse rates. Absence of perianal abscess predicts long-term complete fistula closure.

Synthesis and translation of research and innovations from polio eradication (STRIPE): initial findings from a global mixed methods study

BACKGROUND

Lessons from polio eradication efforts and the Global Polio Eradication Initiative (GPEI) are useful for improving health service delivery and outcomes globally. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a multi-phase project which aims to map, package and disseminate knowledge from polio eradication initiatives as academic and training programs. This paper discusses initial findings from the knowledge mapping around polio eradication activities across a multi-country context.

METHODS

The knowledge mapping phase (January 2018 - December 2019) encompassed four research activities (scoping review, survey, key informant interviews (KIIs), health system analyses). This paper utilized a sequential mixed method design combining data from the survey and KIIs. The survey included individuals involved in polio eradication between 1988 and 2019, and described the contexts, implementation strategies, intended and unintended outcomes of polio eradication activities across levels. KIIs were conducted among a nested sample in seven countries (Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria) and at the global level to further explore these domains.

RESULTS

The survey generated 3955 unique responses, mainly sub-national actors representing experience in over 74 countries; 194 KIIs were conducted. External factors including social, political, and economic factors were the most frequently cited barriers to eradication, followed by the process of implementing activities, including program execution, planning, monitoring, and stakeholder engagement. Key informants described common strategies for addressing these barriers, e.g. generating political will, engaging communities, capacity-building in planning and measurement, and adapting delivery strategies. The polio program positively affected health systems by investing in system structures and governance, however, long-term effects have been mixed as some countries have struggled to institutionalize program assets.

CONCLUSION

Understanding the implementing context is critical for identifying threats and opportunities to global health programs. Common implementation strategies emerged across countries; however, these strategies were only effective where organizational and individual capacity were sufficient, and where strategies were appropriately tailored to the sociopolitical context. To maximize gains, readiness assessments at different levels should predate future global health programs and initiatives should consider system integration earlier to ensure program institutionalization and minimize system distortions.

Significant Left Main Coronary Artery Disease Does Not Incur Any Additional Risk to the Short Term Outcome of Off Pump Coronary Artery Bypass Grafting Surgery

Coronary artery disease is the most common form of heart disease and single most important cause of premature death in developed countries. Off pump coronary artery bypass grafting surgery has recently became widespread internationally and has produced good clinical outcome even in left main coronary artery disease following off pump coronary artery bypass grafting surgery. A prospective observational study was conducted in the department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh from January 2015 to September 2016 after fulfillment of enrollment criteria, 428 patients were studied for the purpose of the study and they were grouped in two, significant left main coronary artery disease in group A and non left main coronary artery disease requiring surgery in group B. Comparison of risk factors between groups demonstrates that diabetes mellitus and smoking habit between two groups were almost identical. 69.2% of patient with significant left main coronary artery group were hypertensive and 25.2% were dyslipidaemic in comparison to non left main coronary artery disease group which were 50.9% and 6.5% respectively. Requirement of per operative inotropic support was significantly higher in left main coronary artery group. 33.6% of patient of left main coronary artery group required per operative inotropic support whereas non left main coronary artery group require 24.8%. Postoperative inotropic support, mechanical ventilation time, ICU stay, hospital stay and complication were similar in both these groups. So, we can say that off pump coronary artery bypass grafting surgery for significant left main coronary artery disease is as safe as non left main coronary artery disease.

A bibliometric analysis of the published road traffic injuries research in India, post-1990

BACKGROUND

Globally, road traffic injuries are the leading cause of death among those aged 15-29 years. However, road traffic injury research has not received adequate attention from the scientific community in low- and middle-income countries, including India. The present study aims to provide a bibliometric overview of research assessing road traffic injuries in India.

METHODS

We used Scopus to extract relevant research in road traffic injuries published from 1991 to 2017. This study presented the key bibliometric indicators such as trends of annual publications and citations, top 10 authors, journals, institutions and highly cited articles, citation analysis of articles, co-occurrence of keywords, etc. Analysis was performed using Scopus, Microsoft Excel, and VOS-viewer.

RESULTS

A total of 242 articles were retrieved with an h-index of 18, excluding self-citations. A steadfast growth of publications was documented in last decade, especially after the year 2010. The h-index of the top 10 authors, institutions, journals and highly cited articles did not surpass single digits. A network visualisation map showed that 'traffic accident', 'male', 'adolescent' and 'child' were the most commonly encountered key terms. The prominent authors were Gururaj G, Dandona R, and Hyder AA, whereas the top journals were the Indian Journal of Forensic Medicine and Toxicology, Medico Legal Update, and the International Journal of Applied Engineering Research and top institutions were the All India Institute of Medical Sciences, New Delhi, the Indian Institute of Technology, Delhi, and the Administrative Staff College of India.

CONCLUSION

In India, road traffic injuries research is inadequate in quantity and quality, warranting greater attention from researchers and policy planners to address the burden of road traffic injuries.

Alteration in steroid hormone and Her-2/neu receptor status following neoadjuvant chemotherapy in locally advanced breast cancer: Experience at a tertiary care centre in India

CONTEXT

Use of neoadjuvant chemotherapy (NACT) in locally advanced breast cancer (LABC) enables tumor reduction and conservative surgery. It is proposed in some studies that there may be an alteration in the hormonal receptor (HR) status and human epidermal growth factor receptor 2 (Her-2)/neu immune-expression following NACT.

AIMS

To study the status of estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu receptor before and after NACT in LABC.

MATERIALS AND METHODS

HR and Her-2/neu status were evaluated by immunohistochemistry on 100 core needle biopsy of primary tumors and surgical specimens after receiving NACT (NACT group); fifty patients without NACT served as non-NACT group, and discordance was compared between the two groups.

RESULTS

In the NACT group, discordance of 17%, 13%, and 11% was noted in ER, PR, and Her-2/neu status, while in non-NACT group, discordance seen in ER, PR, and Her-2/neu was 8%, 8%, and 4%, respectively.

CONCLUSIONS

There was a significant alteration in ER and Her-2/neu status from the core biopsy to the treated resected tumor in the study group. As these changes may impact treatment, HR and Her-2/neu expression reanalysis in final surgical specimens is recommended.

Assessing the impact of a program for late surgical intervention in early-blind children

OBJECTIVE

Many blind children in the developing world are unable to obtain timely treatment due to lack of financial and medical resources. Can public health programs that identify and treat such children several years after the onset of blindness enhance their quality of life? The notion that visual development is subject to an early 'critical period' argues against this possibility. However, there are inadequate empirical data from humans on this issue. To address this need, we examined the quality of life of children living in India and who were treated for early-onset blindness (before one year of age), due to cataracts or corneal opacities.

STUDY DESIGN

Survey study.

METHODS

As part of an ongoing scientific effort named Project Prakash, we screened over 40,000 children in rural northern India to identify those suffering from early-onset blindness. They were provided eye surgeries in a tertiary care ophthalmic center in New Delhi. We subsequently surveyed 64 Prakash children, ranging in age from 5 to 22 years and obtained their responses on a multi-dimensional quality of life questionnaire.

RESULTS

Nearly all of the subjects indicated that their quality of life had improved after treatment. Children reported marked enhancement in their mobility, independence, and safety, and also in social integration. Surprisingly, we found no significant correlations between quality of life metrics and factors such as age at treatment, gender, time since treatment, and pre-surgery and post-surgery acuity.

CONCLUSIONS

A key question for public health policy makers is whether a program of surgical intervention for older blind children is likely to be beneficial, or if the resources are better spent on rehabilitation via vocational training and assistive devices. The marked improvements in quality of life we find in our data strongly argue for the provision of surgical care regardless of a child's age.

A population-based screening program for early detection of common cancers among women in India - methodology and interim results

BACKGROUND

Cancers of the uterine cervix, breast, and oral cavity accounted for 134,420, 115,251, and 24,375 cases, respectively, and were responsible for 52.8% of the total cancers among women in India in 2008.

AIM

The major objectives were to create awareness regarding common cancers among women, to detect pre-cancers of the uterine cervix and oral cavity, and early cancers of the breast, uterine cervix, and oral cavity, by conducting screening with simple, low-cost technology, within the community, and to facilitate confirmation of diagnosis among the screen positives and treatment and follow-up among the diagnosed cases.

SETTINGS AND METHODS

This is a community-based screening program for early detection of breast, uterine cervix, and oral cancers, being implemented among the socioeconomically disadvantaged women in Mumbai, India. The process involves selection of clusters, household surveys, health education, and screening the eligible women for breast, uterine cervix, and oral cancers, by primary healthcare workers, at a temporarily set-up clinic within the community. The program is planned to cover a 125,000 disadvantaged population in five years.

RESULTS

Twenty-one thousand and fifteen people, with 4009 eligible women, have been covered to date. The compliance for screening for breast, cervix, and oral cavity has been 85, 70, and 88% and the screen positivity rates are 3.9, 14.9, and 3.9%, respectively. Twenty-seven oral pre-cancers, 25 cervix pre-cancers, one invasive cancer of the breast, two of the cervix, and one oral cavity cancer have been diagnosed among the screened women and all of them have complied with the treatment.

CONCLUSIONS

The program is raising awareness about the common cancers and harms of tobacco among the disadvantaged women population in Mumbai. It is also helping in detecting pre-cancers and cancers among asymptomatic women and is assisting them in receiving treatment.

Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors

BACKGROUND

Gutkha and pan masala contain harmful and carcinogenic chemicals. Hence, Maharashtra Government banned their manufacture, storage, distribution and sale on 19 th July 2012 for a year.

OBJECTIVES

The objective of this study is to determine the impact of the ban on gutkha and pan masala on its users and vendors.

MATERIALS AND METHODS

A cross- sectional study was conducted among gutkha and/or pan masala users and tobacco vendors in the selected area of Mumbai city, 4-6 months after the implementation of the ban. The parameters studied included knowledge regarding the ban, usage or discontinuation of use of the banned products, product availability, withdrawal symptoms among quitters, etc.,

RESULTS

A total of 68 users and five tobacco vendors were enrolled in this study. Although all users were aware about the ban on gutkha, very few knew about the ban on pan masala. Only 5.9% of users knew that currently the ban had been declared for only 1 year. Electronic media was the main source of information regarding the ban as reported by 45.6% users. All users and vendors were in favor of the ban. After the ban, 23.53% gutkha users quit their habit while 55.88% reduced their gutkha consumption. Non-availability of gutkha was the most important reason stated by the gutkha users for quitting or reducing the consumption. In spite of the ban, gutkha is still available in the market, but at an increased cost or in a different form.

CONCLUSION

Nearly 23.53% of gutkha users have quit their habit post-ban despite its availability through illegal sources.

Community-based tobacco cessation program among women in Mumbai, India

BACKGROUND

Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low- and middle-income countries. Tobacco is addictive; hence, tobacco users need support in quitting.

AIMS

Providing tobacco cessation services to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable "model tobacco cessation program."

SETTINGS AND DESIGN

This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India.

SUBJECTS AND METHODS

It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow-up.

STATISTICAL ANALYSIS

Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco.

RESULTS

The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco.

CONCLUSIONS

Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India.

Use of local anesthesia in transrectal ultrasound guided prostatic biopsy

Transrectal ultrasound (TRUS) guided biopsy of the prostate is the gold standard for detecting prostate cancer. Intraprostatic administration of local anesthesia significantly decreases pain during prostatic biopsy. Transrectal ultrasound guided intraprostatic lidocaine administration along with intrarectally lidocaine gel is a new local anesthesia technique for prostatic biopsy. It was a randomized prospective, comparative, interventional type of the study. A total of 60 patients of age over 55 years included in the study among them 30 patients with transrectal lidocaine gel was in Group I and 30 patients with intraprostatic lidocaine injection with intra rectal gel were in Group II. The mean age was almost identically distributed between the two groups (p=0.668). About 47% of patients in Group I exhibited hard prostate on digital rectal examination (DRE), 33.3% single nodule and 20% multinodule compared to 33.3% of patients in Group II had hard prostate, 26.7% single nodule and 40% multinodule (p=0.236). The mean serum prostate specific antigen (PSA) was significantly higher in Group II than that in Group I (36.7±9.2 vs. 7.5±5.8ng/ml; p=0.007). The mean pain intensity during biopsy was almost two times higher in Group I than in Group II (p<0.001). The present study concludes that the intraprostatic lidocaine injection along with intra rectal lidocaine gel is less painful method and can be considered in all patients undergoing transrectal ultrasound guided prostate biopsy.

Nonfamilial cherubism

Cherubism is a non neoplastic progressive heredity disease affecting the jaw bones. It is a benign disease with a characteristic symmetrical involvement of the maxilla and mandible. It usually affects children before 5 years of age, with painless progressive swelling of the cheeks, frequently associated with dental malformations. Here, we are presenting a case report of a 12-year-old boy suffering from cherubism.

Study of cellular immune response against Hepatitis E virus (HEV)

Hepatitis E virus infection (HEV) is a major cause of acute viral hepatitis in the developing world. The immunopathology of HEV infections has not yet been elucidated. The virus is noncytopathic, and therefore, liver injury may be attributed to immune-mediated damage by cytotoxic T cells and natural killer cells. Therefore, we studied the nature of immune cells involved in HEV-induced liver damage using immunohistochemistry in liver biopsies taken from patients with HEV-induced acute liver failure and demonstrated a significant infiltration of activated CD8(+) T cells containing granzymes. These findings suggest the possible involvement of cytotoxic T cells in disease pathogenesis during HEV infection.

DNA triplex-mediated inhibition of MET leads to cell death and tumor regression in hepatoma

Mesenchymal epithelial transition factor (MET) is one of the critical cell signaling molecules whose aberrant expression is reported in several human cancers. The aim of the study is to investigate the antigene and antiproliferative effect of short triplex forming oligonucleotides, TFO-1 (part of the positive regulatory element) and TFO-2 (away from the transcription start site) on MET expression. HepG2 cells transfected only with TFO-1 (but not with TFO-2 and non-specific TFO) significantly decreased MET levels, which is accompanied by decrease in antiapoptotic proteins and increase in pro-apoptotic proteins. Phosphoproteome-array analysis of 46 intracellular kinases revealed hypophosphorylation of about 15 kinases including ERK, AKT, Src and MEK, suggesting the growth inhibitory effect of TFO-1. Further, the efficacy of TFO-1 was tested on diethylnitrosamine-induced liver tumors in wistar rats. T2-weighted magnetic resonance imaging showed decrease in liver tumor volume up to 90% after treatment with TFO-1. Decreased MET expression and elevated apoptotic activity further indicate that TFO-1 targeted to c-met leads to cell death and tumor regression in hepatoma. Formation of stable DNA triplex between TFO-1 and targeted gene sequence was confirmed by circular dichroic spectroscopy and gel retardation assay. Therefore, it can be concluded that DNA triplex-based therapeutic approaches hold promise in the treatment of malignancies associated with MET overexpression.

Loss of heterozygosity on chromosome 11p15.5 and relapse in hepatoblastomas

BACKGROUND

IGF2 is a tumor suppressor gene at locus 11p15. Many hepatoblastomas have loss of heterozygosity (LOH) at this locus. Earlier studies have not demonstrated any association between LOH and prognosis. Aim of the study was to evaluate the prognostic significance of LOH at 11p15.5 in hepatoblastomas.

METHODS

DNA was isolated from normal liver and tumor tissue in 20 patients with hepatoblastoma. PCR was performed and cases were classified as LOH present, absent or non-informative. Patients' follow-up data was analyzed using Fischer's exact test and Kaplan-Meier survival analysis for relapse-free survival (RFS) in relation to LOH. Ethical clearance was obtained from the institutional ethics board.

RESULTS

All cases were informative for at least one microsatellite marker used. 4 of the 20 cases (20%) had LOH at 11p15.5. One patient died in the immediate postoperative period. 5 of 19 patients relapsed (26%). Of 4 patients who had LOH, 3 (75%) relapsed, the time to relapse being 7, 7 and 9 months, respectively. Of the 15 cases without LOH, 2 (13.3%) relapsed. 4 patients had mixed epithelial and mesenchymal histology; 3 of them had LOH. The 2 groups with and without LOH were well matched. The RFS for patients with LOH (n=4) was 13% (mean survival time [MST]: 8.7 months; 95CI 6.7-10.7), while the RFS for cases without LOH (n=15) was 75% (MST: 100.7 months; 95CI 74.5-126.8).

CONCLUSION

Mixed epithelial and mesenchymal histology is more frequently associated with LOH on chromosome 11p15.5 than pure epithelial histology. LOH on chromosome 11p15.5 is associated with a significantly increased incidence of relapse and a significantly shorter relapse-free survival in patients with hepatoblastoma. The risk of relapse is higher and the RFS lower both in standard-risk and high-risk patients with hepatoblastoma if they demonstrate the presence of LOH at 11p15.5.

Prognostic significance of location of the primary tumor in operable breast cancers

BACKGROUND

The prognostic significance of the primary tumor site in breast cancers is not established with only a few studies having evaluated the issue.

MATERIALS AND METHODS

The relevance of a primary tumor site with respect to systemic disease relapse was evaluated in 187 patients with breast cancer treated with primary surgery and adjuvant chemotherapy, in whom the location of primary tumor was classifiable in any one of the three sites, namely: outer, periareolar, and inner, quadrants. Data was obtained from prospectively maintained records of breast cancer patients treated at a single surgical unit in a tertiary care center.

RESULTS

The three groups were comparable with regard to demographic, pathological tumor, and treatment characteristics. In the multivariate analysis, patients with inner and periareolar quadrant tumors had a higher hazard for systemic disease relapse, (2.53, 95% CI: 1.18-5.42; P = 0.02, and 2.73, 95% CI: 1.04-7.14; P = 0.04, respectively) as compared to outer quadrant tumors. The projected five-year survival estimates in Kaplan Meier were 87%, 61%, and 69%, respectively, for outer, periareolar, and inner quadrant. On further substratification the difference was particularly noted in high risk inner quadrant tumors: age 45, premenopausal patients, tumor size> 2 cms, positive nodes and intermediate or high grade histology, as also in patients treated with breast conservation and CMF, Cyclophosphamide, Methorexate, 5 Fluorouracil chemotherapy.

CONCLUSION

The location of the primary tumor influences survival in breast cancer with inferior outcome for tumors in inner and periareolar quadrants, especially in high risk groups and those treated with conservative approaches. The role of aggressive therapies merits investigation in these patients.

Case report. Schwannoma of both intrahepatic and extrahepatic bile ducts: a rare case

Schwannoma of the biliary tree is extremely uncommon, with only a few cases having been reported so far. They commonly present with obstructive jaundice. Although involvement of the extrahepatic duct is common, occurrence in the intrahepatic ducts has not been reported. We report a case of combined intrahepatic and extrahepatic schwannoma in a 46-year-old man presenting with obstructive jaundice.

Outcome of endoscopic fulguration of posterior urethral valves in children

Posterior urethral valves are the most common cause of congenital obstructive uropathy leading to renal failure in childhood. This study was undertaken to assess the outcome of endoscopic fulguration of posterior urethral valves based upon the clinical, radiological and laboratory findings. This prospective study was carried out on 50 male children with posterior urethral valves who were treated by endoscopic fulguration and came for routine follow-up. Diagnosis of posterior urethral valves (PUV) was confirmed by voiding cystourethrogram (VCUG). After valve ablation, urine R/M/E, urine for culture and sensitivity test, serum creatinine level, USG of KUB including PVR were done in all cases at 1,3,6,12 months and then at six months interval maximum up to 3 years. Mean age of the patients was 2 years ranging from 1 to 12 years old. Mean follow-up period was 30.48 months after valve ablation. At diagnosis mean serum creatinine +/-SD was 90.4+/-44.8 mumol/lit and it decreased to 56.3+/-11.1micromol/lit at the end of 3-years follow-up. Hydronephrotic changes decreased from 84% to 4%. Proteinuria decreased from 38% to 6% and urinary tract infections decreased from 58% to 4% at the end of final follow up. Although the techniques for posterior urethral valves ablation have been refined and the short-term management of patients with posterior urethral valves has improved remarkably, there is growing concern about the long-term outcome. At present endoscopic fulguration with observation is the treatment of choice for posterior urethral valves. In this study patients improved dramatically following fulguration of posterior urethral valves. Early diagnosis and appropriate therapy may arrest progressive damage and facilitate recovery. Further follow-up studies of longer duration are needed.

Solitary fibrous tumour of the liver: a rare imaging diagnosis using MRI and diffusion-weighted imaging

Solitary fibrous tumour of the liver is an extremely rare neoplasm, the reported imaging features of which are largely non-specific. We present a case in which dynamic contrast-enhanced CT, MRI and diffusion-weighted MRI findings suggested a diagnosis of solitary fibrous tumour of the liver that was subsequently confirmed by immunohistochemical evaluation.

Prognostic significance of GSTP1 and MGMT hypermethylation in invasive ductal breast carcinoma patients

Abstract #4053

Purpose: Methylation-mediated suppression of detoxification, DNA repair and tumor suppressor genes has been implicated in cancer development, by shifting cells from the normal cellular cycle to a state of high proliferation that favors tumor development and progression. The current study was designed to analyze the methylation status of these genes in sera of breast cancer patients and determine the correlation of promoter hypermethylation of these genes with disease prognosis and patient survival.&#x2028; Experimental design: To test the hypothesis that promoter methylation of GSTP1 and MGMT is associated with disease prognosis, the methylation status of these genes was analyzed in invasive ductal carcinoma tissues and corresponding sera of breast cancer patients and correlated with disease free survival of these patients.&#x2028; Results: Promoter methylation of GSTP1 and MGMT was observed in 25% and 38% of breast tumor tissues, respectively and in 23% and 35% of the corresponding sera of breast cancer patients. There was significant association between methylation of GSTP1 and advanced tumor stage. Patients harboring methylated GSTP1 were more likely to have disease progression and reduced overall survival compared with patients who did not have the methylated gene.&#x2028; Conclusion: GSTP1 methylation in tumor and sera may serve as a poor prognostic marker in patients with invasive ductal carcinoma.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4053.

Hemorrhagic pseudocyst of the adrenal gland causing acute abdominal pain

Acute abdominal pain is a common clinical entity with varied etiology. Hemorrhagic pseudocysts of the adrenal gland are rare lesions that might be considered in the differential diagnosis of acute abdominal pain. Herein, we report a case of young married female presenting with acute pain abdomen and fever, who was diagnosed to have hemorrhagic pseudocyst of the adrenal gland.

Congenital extrahepatic portosystemic venous shunt: imaging features

Congenital extrahepatic portosystemic venous shunt (CEPS) is a rare anomaly. It causes metabolic derangements and is often associated with liver tumours and other anomalies. Imaging plays an important role in the diagnosis of CEPS. However, it may be misleading in determining the type of shunt. We present a six-year-old girl with CEPS to illustrate the importance of histology in determining the presence of portal veins in the portal triad, which were too small to be seen on imaging.

Non-specific immune parameters of brood Indian major carp Labeo rohita and their seasonal variations

Different non-specific immune parameters and their seasonal changes in brood Indian major carp Labeo rohita reared in two major freshwater aquaculture regions of India viz. West Bengal and Orissa were investigated. It was undertaken for 2 consecutive years and included three main seasons of a year such as summer (March-May), rainy (July-September) and winter (November-January). Total serum protein, albumin and globulin levels were not significantly different throughout the year (p>0.01). Serum lysozyme and myeloperoxidase activities were lower (7.26+/-0.87mg/ml and, 0.54+/-0.11 OD, respectively) in winter as compared to any other season of the year. The bacterial agglutination titer was higher (p<0.01) in the rainy season (8.70+/-1.70) compared to summer and winter seasons (3.40+/-0.60 and 4.00+/-0.89, respectively). Haemagglutination and haemolytic activities did not vary (p>0.01) throughout the year. In blood smears, lymphocyte percentage was higher (75-80%) as compared to those of neutrophil (10-15%) and monocytes (5-10%) but eosinophilic granulocytes were present only in few cases. The differential leucocyte count did not vary significantly (p>0.05) in any season. This study indicated that certain non-specific immune parameters of this species can be modulated at certain times of the year.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer

BACKGROUND

In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND).

AIMS

This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis.

SETTINGS AND DESIGN

Cross-sectional study of 40 breast cancer patients.

MATERIALS AND METHODS

Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation.

RESULTS

SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13).

STATISTICAL ANALYSIS

We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate.

CONCLUSION

Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Passive transfer of maternal antibodies and their existence in eggs, larvae and fry of Indian major carp, Labeo rohita (Ham.)

Lack of immune competence in the early stages of life leads to severe mortality in larval stages of different fish species including Indian major carp (IMC). Investigation through indirect enzyme linked immunosorbent assay (ELISA) and agglutination test revealed a significant increase in specific serum antibody response in the brood fish of Indian major carp, Labeo rohita (Ham.) following immunisation with a virulent Aeromonas hydrophila bacterin 1 month prior to breeding, which was transferred to larvae through the egg. No significant differences (P > 0.05) in mean antibody levels in larvae at the 1st and 2nd weeks post-hatch was recorded while a slight rise in antibody level was observed in 3-week-old fry, perhaps due to exposure to A. hydrophila present in the aquatic environment. Immunised brood fish serum, egg and larval extracts in non-reducing sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and subsequent western blot analysis revealed an antibody molecule of approximate molecular weight 210 kDa. On challenge with virulent A. hydrophila, a significant reduction in mortality was recorded in immunised larvae and fry (58.0, 43.75 and 37.14% in the 1st, 2nd and 3rd week, respectively) relative to control fish (87.0, 79.0 and 76.4% in 1st, 2nd and 3rd week, respectively). The present study indicated the role of maternally derived antibody in protection of hatchlings of Indian major carp against specific pathogens.

Neoadjuvant chemotherapy in squamous cell carcinoma of the esophagus using low dose continuous infusion 5-fluorouracil and cisplatin: results of a prospective study

BACKGROUND

Surgery is the treatment of choice for localized esophageal squamous cell carcinoma (ESCC). Despite curative surgical resection, the majority of patients develop local and systemic recurrence with poor 5-year survival.

AIMS

To study the role of low dose continuous infusion (CI) 5-fluorouracil (5-FU) and cisplatin as neoadjuvant chemotherapy in ESCC.

SETTINGS AND DESIGN

A non-randomized prospective study conducted over a period of two years (1996-1998) in the Department of Surgery, All India Institute of Medical Sciences, India.

MATERIAL AND METHODS

Twenty-two patients with ESCC were included in the study. Chemotherapy consisted of a continuous 30-day infusion of 5-FU (350 mg/m2/day) and cisplatin (7.5 mg/m2/day), 5 days/week for 4 weeks. All patients had surgery following chemotherapy.

RESULTS

A full course of chemotherapy was completed in 18 patients (82%). Chemotherapy was not completed due to non-compliance (n=2), thrombophlebitis (n=1), and vomiting (n=1). Grade-1 haematological and hepato-toxicity was observed in four patients. Thirteen patients developed thrombophlebitis. After chemotherapy, improvement in dysphagia was observed in 13 of 22 (59%) patients. Radiological partial response was observed in 8 patients (36.4%). 19 patients underwent surgical resection (86.4%) with zero mortality. Post-operative morbidity was observed in six patients (27%). Complete and partial pathological response was observed in two (11%) and one patient (5.5%) respectively. The overall median survival was 18 months and 4-year survival was 42%.

CONCLUSIONS

Low dose CI 5-FU and cisplatin is well tolerated with minimal toxicity. Histopathological response rates and survival figures are comparable with the more toxic neoadjuvant chemotherapeutic regimens.

Wegener's granulomatosis: an isolated lung mass responding to antituberculosis therapy and atypical course

We describe an unusual case of Wegener's granulomatosis (WG), in a middle aged, non-smoking female who presented with a lung mass with constitutional symptoms. FNABC from mass revealed a single ill-defined granuloma without necrosis. There was a definite clinical and radiological response to anti-tuberculosis treatment. She was later found to have another mass lesion in nasopharynx. ANCA was negative initially but became positive once disease flare up occurred. Multisystem involvement with clinical features of vasculitis were seen during the flare up and resulted in a fatal outcome. Unusual features and literature on this entity is discussed.

Intussusception due to gastrointestinal stromal tumour of the colon: diagnosis by colonoscopy

Intussusception of the intestine is rare in adults. We report a case of a 45-year-old male who presented with long-standing pyrexia of unknown origin, abdominal pain, gastrointestinal bleeding and constitutional symptoms. Colonoscopic examination revealed a large invaginated mass suggestive of colonic intussusception due to gastrointestinal stromal tumour of the colon. His symptoms disappeared after surgical removal of the tumour.

Symptom score does not correlate with gastritis grade and Helicobacter pylori infection in non ulcer dyspepsia

BACKGROUND

Non ulcer dyspepsia (NUD) is being postulated as one of the gastroduodenal manifestations of H. pylori infection. H. pylori infection may result in clinical symptoms as well as histological changes in NUD.

AIM

To compare clinical symptom score and histological changes in H. pylori (Hp) positive and negative untreated NUD patients.

METHODS

Forty six patients with dyspeptic symptoms and normal upper GI endoscopic examinations were included in this study. During endoscopy 2 biopsies each were taken from the antrum and body of the stomach. These biopsies were used for rapid urease test (RUT) and histological examination. Patients were diagnosed to have Hp infection if either of two tests were positive. There were two groups of patients: Hp positive and Hp negative NUD patients. Clinical scoring using Glasgow dyspepsia score (Max. 20) and histological analysis, using Sydney system (Max score 11) was done and compared for both the groups of patients. Clinical scoring, RUT and histological scoring were blinded to each other.

RESULTS

H. pylori was present in 29(63%) of the 46 patients. Mean clinical score for H. pylori positive patient was 10.9 while for Hp negative patient was 11.4. Total histological score for Hp positive and Hp negative patients was 3.37 Vs 1.76 (antrum) and 3.68 Vs 1.29(body) (p < .001), respectively. The only histological change found to be statistically significant between Hp positive and Hp negative patients was presence of lymphoid follicles (p < .05).

CONCLUSION

Clinical scoring does not correlate with the presence of H pylori or histological severity. In NUD patients positive for H. pylori, there is a significant increase in the severity of gastritis both in the antrum and the body.

Hepatic technetium-99m-mebrofenin iminodiacetate scans and serum gamma-glutamyl transpeptidase levels interpreted in series to differentiate between extrahepatic biliary atresia and neonatal hepatitis

Hepatic technetium-99m-mebrofenin iminodiacetate (99mTc-mebrofenin IDA) scans and serum gamma-glutamyl transpeptidase (GGTP) have high sensitivity for extrahepatic biliary atresia (EHBA). This study was based on the hypothesis that the interpretation of results of 99mTc-mebrofenin IDA scans and serum GGTP levels in series would result in a reduction of the false positivity observed with these tests individually. The aetiology of neonatal cholestasis in 132 study patients was: 25% (33/132) EHBA, 45.5% (60/132) neonatal hepatitis (NH) with an identifiable cause and 19.7% (26/132) idiopathic NH. Of the various clinical, biochemical and imaging parameters that were significantly different between patient groups, sensitivity for EHBA was: serum GGTP > or = 150 IU l(-1) (100%), 99mTc-mebrofenin IDA scans (100%), pale stools (82.8%) and total serum bilirubin > or = 12 mg dl(-1) (66%). However, specificity ranged from 48.5 to 79%. Of the 63 patients who had non-excreting IDA scans, operative cholangiograms could be avoided on the basis of a specific aetiological diagnosis of NH, made concurrently, in only 9 infants. The rest (54) underwent operative cholangiograms; 21 (39%) of these had patent biliary trees and therefore underwent the procedure unnecessarily. If serum GGTP (< 150 IU l(-1)) had been used as a screen after IDA scanning in these 54 patients, operative cholangiograms could have been avoided in another 12 patients and thereafter only 9/42 (21%) of the operative cholangiograms would have been considered unnecessary.

CONCLUSION

A diagnostic algorithm is proposed wherein serum GGTP level (at a cut-off level that maintains 100% sensitivity for EHBA) is used in series with non-excreting 99mTc-mebrofenin IDA scans (for patients with no specific aetiological label). This strategy reduces the false positivity of individual tests.

Ectopic pancreas associated with a choledochal cyst and extrahepatic biliary atresia

Two children with incidentally-diagnosed ectopic pancreatic tissue in the jejunum at surgery for extrahepatic biliary atresia (EHBA) and choledochal cyst (CC) are reported. No case has been reported in the literature describing the association of a CC with ectopic pancreas, and only one case of EHBA associated with ectopic pancreas has been reported. We believe that incidentally-detected ectopic pancreatic tissue should be excised, even though the patient is symptom-free, in order to prevent the risk of serious complications due to either the mass effect or the potential for acute pancreatitis, cystic degeneration, or malignant transformation at a later date.

Utility of fine-needle aspiration cytology in the classification of leprosy

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study

OBJECTIVE

To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA).

MATERIAL AND METHODS

Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study.

RESULTS

We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA.

CONCLUSIONS

The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

Renal function and structure in subacute hepatic failure

BACKGROUND AND AIMS

Subacute hepatic failure (SHF) is a fatal complicaton of acute viral hepatitis. Renal failure has been implicated as the main cause of death in this disease. However, renal functional and structural evaluation in such patients have not been performed. The present prospective study evaluated the renal functional and structural abnormalities in patients with subacute hepatic failure.

METHODS

Fourteen consecutive patients with SHF, 11 with acute liver failure (ALF) and 15 with cirrhosis of the liver (Child's B or C) were included in the present study. All 40 patients had liver disease caused by hepatitis viruses. The glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) estimations were measured in all patients by the use of technetium-99m diethylenetriaminepentaacetic acid and [131I]-labeled ortho-iodohippuric acid, respectively. Ante-mortem or post-mortem liver biopsies were performed in all patients. In three patients with SHF, post-mortem kidney biopsies were also performed.

RESULTS

Thirty six percent (5/14) of patients with SHF, 18% (2/11) of patients with ALF and 20% (3/15) of patients with cirrhosis had renal failure. Seven patients with SHF, seven with ALF and nine with cirrhosis died. All the patients with renal failure in each of the three groups were among the deceased patients. Glomerular function was markedly affected among patients with SHF, which was shown by significantly higher (P < 0.05) proteinuria levels (0.367 +/- 0.38 g/24 h) compared to levels in patients with ALF (0.178 +/- 0.11 g/24 h) and cirrhosis (0.212 +/- 0.133 g/24 h). The GFR in SHF (56 +/- 27 mL/min per 1.73 m2) and cirrhotic patients (58 +/- 36 mL/min per 1.73 m2) was significantly lower compared to those in ALF patients (102 +/- 51 mL/min per 1.73 m2; P < 0.05). A significantly higher proportion (P < 0.05) of patients with SHF and cirrhosis (64 and 73%, respectively) had a GFR below 80 mL/min per 1.73 m2 compared to patients with ALF (18%). The GFR value among the deceased SHF patients (46 +/- 26 mL/min per 1.73 m2) was significantly lower (P < 0.05) than those SHF patients who survived (65 +/- 25 mL/min per 1.73 m2). However, similar features could not be documented among patients with ALF or cirrhosis. Subtle structural changes in the glomerulus were also noted in patients with SHF. These included mesangial proliferation and thickening, basal membrane thickening and increased cellularity with interstitial edema. The ERPF was markedly reduced (P = 0.058) among patients with SHF (347 +/- 131 mL/min per 1.73 m2) and cirrhosis (395 +/- 137 mL/min per 1.73 m2) in comparison to ERPF documented among patients with ALF (436 +/- 217 mL/min per 1.73 m2). Such a reduction in renal tubular blood flow, along with histologic documentation of hyaline presence, bile and grannular cast in the tubule, indicated a possible tubular dysfunction in patients with SHF.

CONCLUSION

It is concluded that glomerular and tubular dysfunction with subtle structural abnormalities does occur in patients with SHF. These are similar to renal changes in cirrhosis and may have similar pathogenetic mechanisms that require further evaluation.

Conjunctival dysfunction and mitomycin C-induced hypotony

PURPOSE

To determine the role of a physically intact conjunctiva in the development of chronic hypotony after mitomycin C-enhanced trabeculectomy.

METHOD

Three patients with mitomycin C-related hypotonic maculopathy, but without a leak on Siedel test, had a thorough evaluation of the bleb area and an anterior segment fluorescein angiography. The bleb was excised and a pedicle flap, rotated from the temporal conjunctiva, was sutured to cover the defect superiorly. The scleral flap and its sutures were not disturbed. The excised bleb was subjected to light and electron microscopy.

RESULTS

The Seidel test result was negative in all patients, but late phases of the anterior segment angiography showed a generalized seepage of aqueous from the bleb. After revision of the bleb, there was a gradual increase in the intraocular pressure, a reversal of the hypotonic maculopathy, and consequent improvement in visual acuity in all three patients, stable up to a minimum follow-up of 18 months. On histopathologic examination, the basement membrane was thickest under thin areas of the epithelium and thinnest below thicker epithelial layers.

CONCLUSION

A dysfunctional conjunctival barrier, as evidenced by the "sweating" of the bleb and histopathologic alterations in the epithelial barrier, could be responsible for the hypotonic maculopathy in these patients. Excision of the conjunctiva alone and replacement by a pedicle conjunctival graft offers a safe and effective method of treating chronic hypotony after mitomycin C-augmented trabeculectomy in such patients.

Acute hepatic failure in India: a perspective from the East

Acute hepatic failure (AHF) in India almost always presents with encephalopathy within 4 weeks of the onset of acute hepatitis. Further subclassification of AHF into hyperacute, acute and subacute forms may not be necessary in this geographical area, where the rapidity of onset of encephalopathy does not seem to influence survival. Viral hepatitis is the cause in approximately 95-100% of patients, who therefore constitute a more homogeneous population than AHF patients in the West. In India, hepatitis E (HEV) and hepatitis B (HBV) viruses are the most important causes of AHF; approximately 60% of cases are caused by to these viruses. Hepatitis B virus core mutants are very important agents in cases where hepatitis B results in AHF in this country. Half of the patients with AHF admitted to our centre are female, one-quarter of whom are pregnant. Therefore, pregnant females who contract viral hepatitis constitute a high-risk group for the development of AHF. However, the outcome of AHF in this group is similar to that in non-pregnant women and men. No association with any particular virus has been identified among sporadic cases of AHF. In our centre, approximately one-third of AHF patients survive with aggressive conservative therapy, whereas two-thirds of deaths occur within 72 h of hospitalization. Cerebral oedema and sepsis are the major fatal complications. Both fungal and gram-negative bacteria are major causes of sepsis. Among patients with AHF, despite the presence of sepsis, its overt clinical features (i.e. fever, leucocytosis) may be absent and objective documentation of the presence of sepsis in such patients is achieved by repeated culture of various body fluids. It should be possible to develop simple, clinical prognostic markers for AHF in this geographical region, in order to identify patients suitable for liver transplantation.

Epithelioid hemangioendothelioma of the greater omentum: report of a case

We report herein the case of an 11-year-old girl found to have an epithelioid hemangioendothelioma of the greater omentum. The child presented with a 4-month history of vague lower abdominal pain and gradually increasing generalized distension. Her symptoms and signs could not be ascribed to any specific organ system. Ultrasonography and computerized axial tomography revealed a mass lesion anterior to the bowel loops and a laparotomy revealed a huge lobulated mass, arising from the greater omentum, which was completely excised. She has remained well postoperatively without any adjunctive chemotherapy or radiotherapy.

Differential binding of proteins to peroxisomes in rat hepatoma cells: unique association of enzymes involved in isoprenoid metabolism

Farnesyl diphosphate synthase (FPPS: EC2.5.1.10), a key enzyme in isoprenoid metabolic pathways, catalyzes the synthesis of farnesyl diphosphate (FPP) an intermediate in the biosynthesis of both sterol and non-sterol isoprenoid end products. The localization of FPPS to peroxisomes has been reported (Krisans, S. K., J. Ericsson, P. A. Edwards, and G. A. Keller. 1994. J. Biol. Chem. 269: 14165;-14169). Using indirect immunofluorescence and immunoelectron microscopic techniques we show here that FPPS is localized predominantly in the peroxisomes of rat hepatoma H35 cells. However, the partial release of 60;-70% of cellular FPPS activity is observed by selective permeabilization of these cells with digitonin. Under these conditions, lactate dehydrogenase, a cytosolic enzyme, is completely released whereas catalase, a known peroxisomal enzyme, is fully retained. Digitonin treatment of H35 cells differentially affects the release of other peroxisomal enzymes involved in isoprenoid metabolism. For instance, mevalonate kinase and phosphomevalonate kinase are almost totally released (95% and 91%, respectively), whereas 3-hydroxy-3-methylglutaryl-CoA reductase is fully retained. Indirect immunoflourescence studies indicate that FPPS is localized in peroxisomes of Chinese hamster ovary (CHO)-K1 cells but is dispersed in the cytosol of ZR-82 cells, a mutant that lacks peroxisomes. Unlike in H35 cells, FPPS is completely released upon digitonin permeabilization of CHO-K1 and ZR-82 cells. In contrast, under the same permeabilization conditions, catalase is fully retained in CHO-K1 cells but completely released from ZR-82 cells. These studies indicate that FPPS and other enzymes in the isoprenoid biosynthetic pathways, involved in the formation of FPP, are differentially associated with peroxisomes and may easily diffuse to the cytosol. Based on these observations, the significance and a possible regulatory model in the formation of isoprenoid end-products are discussed.