Robotic excision of vaginal pouch in ovotesticular disorder of sexual development

ABSTRACT Purpose: Ovotesticular disorder of sexual development (DSD) is the rarest of DSDs with an incidence of 1:20000 (1). Management of vaginal pouches in such cases is warranted for symptomatic presentations and laparoscopy is considered the gold standard treatment (2). We report a rare case of robotic excision of a large symptomatic vaginal pouch in a 19-year-old boy with ovotesticular DSD. Material and Methods: A 19-year-old boy with ovotesticular DSD post hypospadias repair in early childhood presented with complaints of recurrent UTIs, ballooning of urethra during micturition and post-void dribbling. Ultrasound, voiding cystourethrogram (VCUG) and magnetic resonance imaging (MRI) were suggestive of a vaginal pouch. The patient underwent endo-evaluation followed by robot-assisted excision of the vaginal pouch. Endo-evaluation showed two orifices in the posterior urethra. The posterior orifice was leading into a blind-ending rudimentary uterus and the true urethra was lying anteriorly. The DaVinci Xi Robotic Surgical System was used and the entire pouch was dissected free of the surrounding tissues using monopolar scissors. The pouch was transected just a few millimetres from its junction with the urethra. The urethra was then closed with V-loc 4-0 suture. The patient was discharged on postoperative day 2 and the catheter was removed on day 21. Results: Follow-up VCUG at 6 weeks did not show any residual pouch. There was no complaint of post-void dribbling or UTI at 30 months of follow-up. Conclusion: Robot-assisted laparoscopy should be considered as an alternative to laparoscopy for the primary treatment of a large symptomatic vaginal pouch.

Cathepsin S as an early biomarker for cardiovascular disease in chronic kidney disease patients / Catepsina S como um biomarcador precoce para doença cardiovascular em pacientes com doença renal crônica

Abstract Introduction: A high incidence of cardiovascular disease (CVD) events and premature mortality is observed in patients with chronic kidney disease (CKD). Thus, new biomarkers that may help predict the development of CVD in early stages of CKD are being investigated along with other traditional risk factors. Objective: To investigate cathepsin S as an early biomarker for CVD in patients with CKD. Methods: A total of 64 patients with CKD were included and classified into 2 groups: CKD patients with established CVD and CKD patients with non-established CVD. All patients were submitted to routine investigations including complete blood count, random blood sugar, glycated hemoglobin (HbA1c), serum electrolytes, urea, creatinine, total protein, total albumin, calcium total, phosphorous, uric acid, vitamin D, parathormone, lipid profile, liver function test, measurement of serum cathepsin S (Cat S), and 2D Echo of the heart. Results: The level of serum Cat S was increased in CKD patients with CVD (p <0.05) as well as in later stages of CKD (p <0.05). CVD was also more common in patients in early stage CKD. In early stages CKD, Cat S and CVD were positively correlated. Conclusion: These findings suggest that serum Cat S might be useful as an early biomarker for CVD in CKD patients.

Resumo Introdução: Uma alta incidência de eventos de doença cardiovascular (DCV) e mortalidade prematura é observada em pacientes com doença renal crônica (DRC). Assim, novos biomarcadores que podem ajudar a prever o desenvolvimento de DCV nos estágios iniciais da DRC estão sendo investigados juntamente com outros fatores de risco tradicionais. Objetivo: Investigar a catepsina S como um biomarcador precoce para DCV em pacientes com DRC. Métodos: Um total de 64 pacientes com DRC foram incluídos e classificados em 2 grupos: pacientes com DRC com DCV estabelecida e pacientes com DRC com DCV não estabelecida. Todos os pacientes foram submetidos a investigações de rotina incluindo hemograma completo, glicemia aleatória, hemoglobina glicada (HbA1C), eletrólitos séricos, ureia, creatinina, proteína total, albumina total, cálcio total, fósforo, ácido úrico, vitamina D, paratormônio, perfil lipídico, teste de função hepática, medição da catepsina S sérica (Cat S), e Eco 2D do coração. Resultados: O nível de Cat S sérica esteve aumentado em pacientes com DRC com DCV (p <0,05), bem como em estágios posteriores da DRC (p <0,05). A DCV também foi mais comum em pacientes com DRC em estágio inicial. Em estágios iniciais da DRC, a Cat S e a DCV foram positivamente correlacionadas. Conclusão: Estes achados sugerem que a Cat S sérica pode ser útil como um biomarcador precoce para DCV em pacientes com DRC.

Digital infarct and mononeuritis in a middle aged female: always suspect Antineutrophil cytoplasmic antibodies associated vasculitis

Vasculitis is a process caused by inflammation of blood vessel walls and results in a variety of disorders. Small-vessel vasculitis (vasculitis involving arteries, venules and capillaries) should be suspected in any patient who presents with a multisystem disease that is not caused by an infectious or malignant process. Testing for Antineutrophil cytoplasmic antibody (ANCA) is the basis of classification of small vessel vasculitis into ANCA associated and non - ANCA associated vasculitis. Apart from cutaneous manifestations like palpable purpura and vasculitic urticaria, digital gangrene in a patient with evidence of mononeuritis multiplex is highly suggestive of ANCA associated vasculitis (AAV). Clinically most of these vasculitides have overlapping clinical presentations and similar treatment. Early diagnosis and rapid initiation of treatment of AAV is recommended rather than ordering for definitive tests (e.g. histopathology or angiograms) since delay in treatment can result in serious end organ damage (pulmonary or renal).

Vaginal Graft Substitution Urethroplasty For Female Urethral Strictures: A Good Alternative To Lingual/Buccal Mucosal Graft

Post-menopausal sub meatal stenosis used to be common in elderly ladies, but urethral strictures were not so common. With more frequent urethral manipulations and indwelling catheterization incidence of stricture has increased. Lingual or buccal mucosal substitution urethroplasty has become standard treatment option for female urethral stricture with good long-term result. Acceptance of this procedure in female is guarded due to donor site morbidity.We used vaginal graft for substitution in 11 patients after thorough evaluation with follow-up ranging from 3 months to 2 years with satisfactory outcome and no donor site morbidity.

Complicated UTI – A Rare Cause of Spontaneous Perirenal Hematoma.

Spontaneous renal hemorrhage is an unusual complication of urinary tract infection. A 56-year-old man, diabetic with single functional kidney was admitted with fever and abdominal pain for one day. He had pyuria and an obstructed renal moiety due to a lower ureteric stone. On evaluation, he was found to have a left perirenal hemorrhage. Drainage of the obstructed system was performed and hemorrhage was managed conservatively; in the postoperative period patient remained stable and was discharged. In conclusion, complicated urinary tract infection is a rare cause of the spontaneous perirenal hematoma and needs a high vigilance for diagnosis and management.

Coeliac disease in patients with short stature: A tertiary care centre experience.

Background. We aimed to determine the prevalence of coeliac disease among children with short stature at a tertiary care centre and to define the predictors for coeliac disease, if any, in them. Methods. In this retrospective study, we reviewed the case records of children and adolescents with growth retardation attending the Paediatric Endocrinology Clinic from January 2008 to June 2011. All patients underwent the multi-tier stratified diagnostic protocol for complete evaluation of short stature. Coeliac disease was screened using IgA-anti-tissue transglutaminase antibody. The diagnosis of coeliac disease was made on the basis of the modified European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria. Results. Of 432 patients (238 boys) who presented with short stature, 72 (16.7%) had physiological, while 360 (83.3%) had pathological causes. Endocrine causes were growth hormone deficiency (86 patients, 19.9%), hypopituitarism (31, 7.2%), hypothyroidism (22, 5.1%) and others (7, 1.6%). The systemic causes were: coeliac disease (47, 10.9%), haematological diseases (14, 3.2%), renal diseases (11, 2.5%) and others (24, 5.6%). Chronic diarrhoea (OR 15.7, 95% CI 7.8–31.5) and anaemia (OR 4.9, 95% CI 1.9–12.7]) were significant predictors for coeliac disease in patients with short stature. There was a definite response to gluten-free diet in them and the mean (SD) growth velocity measured over at least 6 months of gluten-free diet was 8.1 (3.0) cm/year. Conclusion. Nearly 11% of patients presenting with short stature have coeliac disease. In these patients chronic diarrhoea and anaemia were significant predictors of coeliac disease.

Janani Suraksha Yojana: the conditional cash transfer scheme to reduce maternal mortality in India – a need for reassessment.

Alongside endorsing Millennium Development Goal 5 in 2000, India launched its National Population Policy in 2000 and the National Health Policy in 2002. However, these have failed thus far to reduce the maternal mortality ratio (MMR) by the targeted 5.5% per annum. Under the banner of the National Rural Health Mission, the Government of India launched a national conditional cash transfer (CCT) scheme in 2005 called Janani Suraksha Yojana (JSY), aimed to encourage women to give birth in health facilities which, in turn, should reduce maternal deaths. Poor prenatal care in general, and postnatal care in particular, could be considered the causes of the high number of maternal deaths in India (the highest in the world). Undoubtedly, institutional delivery in India has increased and MMR has reduced over time as a result of socioeconomic development coupled with advancement in health care including improved women’s education, awareness and availability of health services. However, in the light of its performance, we argue that the JSY scheme was not well enough designed to be considered as an effective pathway to reduce MMR. We propose that the service-based CCT is not the solution to avoid/reduce maternal deaths and that policy-makers and programme managers should reconsider the ‘package’ of continuum of care and maternal health services to ensure that they start from adolescence and the pre-pregnancy period, and extend to delivery, postnatal and continued maternal health care.

Differential response to sustained stimulation by hCG & LH on goat ovarian granulosa cells.

Background & objectives: Chapekar established a model of ovarian tumourigenesis in mice by splenic transplantation of ovaries, resulting in sustained luteinizing hormone (LH) levels because of absence of feedback inhibition. There is increasing evidence of the differential response to LH or hCG under various experimental conditions. The effect of sustained hormonal stimulation in long term cultures is sparsely investigated. The study is aimed to determine the role of hCG and LH stress on caprine ovarian granulosa cells and their downstream signaling in short and long term cultures. Methods: To study the response of hCG and LH stress and downstream signaling, short term cultures were set up by exposing goat ovarian granulosa cells in primary cultures to hCG and LH stress (levels beyond their physiological doses) for 5 days (P0). Cells were sub-cultured at sixth day and subjected to prolonged LH/ hCG stress for two weeks in passage 1(P1) (long term cultures). Downstream cell signaling molecules were assessed. Intracellular cAMP was estimated by ELISA. For PKA and PKC, activity assays were performed. pERK protein expressions in short term cultures were assessed by Western blot and flowcytometry; in long term cultures, pERK expression was analyzed by flowcytometry. Results: Differential effects on cell proliferation were observed in long term cultures, where the untreated and hCG exposed cells showed markedly reduced cell proliferation after second week of exposure while LH treated cells continued to proliferate. Different levels of cAMP, PKA, PKC and phosphorylated ERK1/2 were observed on short term and long term LH stimulation. On sustained hormonal stimulation, cAMP levels were significantly (P<0.05) higher in hCG treated cultures as compared to controls and LH treated cultures. LH led to maximal elevation of ERK in long term cultures. Interpretation & Conclusions: As pERK1/2 promotes cellular proliferation, activation of ERK1/2 in LH treated cultures may be responsible for sustained growth. Prolonged LH treatment promoted growth and proliferation in caprine ovarian granulosa cells whereas prolonged exposure to hCG led to elevated levels of cAMP and decreased the rate of proliferation. Defining the signals and second messengers that act as survival or apoptotic mediators may help in elucidation of the mechanisms controlling proliferation or programmed cell death in granulosa cells.

Chemical composition and antibacterial properties of the essential oil and extracts of Lantana camara Linn. from Uttarakhand (India)

Objective: The purpose of this study was to evaluate the essential oil composition as well as antibacterial activities of essential oil and leaves extracts of Lantana camara against five bacterial strains. Methods: Essential oil was obtained by hydro-distillation from the leaves and analyzed by GC and GC-MS. The antibacterial activities of essential oil and the leaves extracts were tested by using disk diffusion method against five bacterial strains. Results: Thirty seven compounds were identified representing 98.11% of the total oil, of which trans-caryophyllene (13.95%), bicyclogermacrene (9.77%), α-curcumene (8.57%), sabinene (8.28%), (E)-citral (6.90%), 1,8 cineole (5.06%), α-pinene (4.03%), γ-terpinene (3.83%) and germacrene D (3.13%) were detected as major components. In respect to the antibacterial activities, essential oil showed the high degree of sensitivity against Micrococcus luteus, Escherichia coli, Staphylococcus aureus and Bacillus cereus except Pseudomonas aeruginosa while extracts of leaves obtained through petroleum ether, benzene, methanol and water exhibited good to moderate antimicrobial activity against all tested bacterial strains. Conclusions: The present study suggested that M. luteus showed best zone of inhibition for the essential oil as well as aqueous extract among all the tested bacterial strains. The most active extract can be subjected to isolation of the therapeutic antimicrobials to carry out further pharmacological evaluation.

Needle stick injuries among health care workers in a tertiary care hospital of India.

Background & objectives: Percutaneous injuries caused by needlesticks, pose a significant risk of occupational transmission of bloodborne pathogens. Their incidence is considerably higher than current estimates, and hence a low injury rate should not be interpreted as a non existent problem. The present study was carried out to determine the occurrence of NSI among various categories of health care workers (HCWs), and the causal factors, the circumstances under which these occur and to, explore the possibilities of measures to prevent these through improvements in knowledge, attitude and practice. Methods: The study group consisted of 428 HCWs of various categories of a tertiary care hospital in New Delhi, and was carried out with the help of an anonymous, self-reporting questionnaire structured specifically to identify predictive factors associated with NSIs. Results: The commonest clinical activity to cause the NSI was blood withdrawal (55%), followed by suturing (20.3%) and vaccination (11.7%). The practice of recapping needles after use was still prevalent among HCWs (66.3%). Some HCWs also revealed that they bent the needles before discarding (11.4%). It was alarming to note that only 40 per cent of the HCWs knew about the availability of PEP services in the hospital and 75 per cent of exposed nursing students did not seek PEP. Interpretation & conclusions: The present study showed a high occurrence of NSI in HCWs with a high rate of ignorance and apathy. These issues need to be addressed, through appropriate education and other interventional strategies by the hospital infection control committee.