Vitamin D Trajectory after Total Knee Arthroplasty: A Method for Quick Correction in Deficient Patients

Background@#It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA. @*Methods@#Vit D levels 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p 0.05) between group III and group I. @*Conclusions@#We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

P-I metalloproteinases and L-amino acid oxidases from Bothrops species inhibit angiogenesis

Snake venoms are composed of pharmacologically active proteins that are evolutionarily diverse, stable and specific to targets. Hence, venoms have been explored as a source of bioactive molecules in treating numerous diseases. Recent evidences suggest that snake venom proteins may affect the formation of new blood vessels. Excessive angiogenesis has been implicated in several pathologies including tumours, diabetic retinopathy, arthritis, inter alia. In the present study, we have examined the effects of P-I metalloproteinases isolated from Bothrops moojeni (BmMP-1) and Bothrops atrox (BaMP-1) and L-amino acid oxidases (LAAO) isolated from B. moojeni (BmLAAO) and B. atrox (BaLAAO) on biochemical and functional aspects of angiogenesis. Methods: P-I metalloproteinases and LAAO were purified from venom by molecular size exclusion and ion-exchange chromatography and subsequently confirmed using mass spectrometry. The P-I metalloproteinases were characterized by azocaseinolytic, fibrinogenolytic and gelatinase activity and LAAO activity was assessed by enzyme activity on L-amino acids. Influence of these proteins on apoptosis and cell cycle in endothelial cells was analysed by flow cytometry. The angiogenic activity was determined by in vitro 3D spheroid assay, Matrigel tube forming assay, and in vivo agarose plug transformation in mice. Results: P-I metalloproteinases exhibited azocaseinolytic activity, cleaved α and partially β chain of fibrinogen, and displayed catalytic activity on gelatin. LAAO showed differential activity on L-amino acids. Flow cytometry analysis indicated that both P-I metalloproteinases and LAAO arrested the cells in G0/G1 phase and further induced both necrosis and apoptosis in endothelial cells. In vitro, P-I metalloproteinases and LAAO exhibited significant anti-angiogenic properties in 3D spheroid and Matrigel models by reducing sprout outgrowth and tube formation. Using agarose plug transplants in mice harbouring P-I metalloproteinases and LAAO we demonstrated a marked disruption of vasculature at the periphery. Conclusion: Our research suggests that P-I metalloproteinases and LAAO exhibit anti-angiogenic properties in vitro and in vivo.(AU)

Vitamin D Trajectory after Total Knee Arthroplasty: A Method for Quick Correction in Deficient Patients

Background@#It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA. @*Methods@#Vit D levels 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p 0.05) between group III and group I. @*Conclusions@#We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

Gallbladder motility in children with chronic functional abdominal pain

Background: Chronic abdominal pain is a common gastrointestinal symptom in children that significantly lowers their quality of life. In adults, Gall bladder (GB) hypomotility / dyskinesia is associated with many functional abdominal disorders but there is scarcity of evidence on its role in childhood gastro-intestinal disorders. Aim of the study is to evaluate the GB motility in children with chronic functional abdominal pain (FAP).Methods: Children aged 5-15 years with chronic abdominal pain fulfilling ROME-III criteria and healthy controls were included and all study participants were subjected to ultrasonographic evaluation of the gall bladder volume in fasting state and post - Fatty test meal (FTM) and its ejection fraction was calculated.Results: Sixtysix children including 31 with chronic FAP underwent sonographic evaluation for GB motility. The mean ejection fraction (EF) of cases and controls were 51.72'17.76% and 57.3'23.26% (p'value - 0.158). The mean EF of cases with upper abdominal pain and lower/peri-umbilical abdominal pain were 41.7'17.1% and 57.2'15.9% respectively (p'value < 0.0001). Increasing BMI had no significant association with GB motility among the participants.Conclusions: There is lack of significant association between children with chronic FAP and GB hypomotility. Children with upper abdominal pain have lesser GB EF, suggesting a possible abnormal GB motility.

Clinical and laboratory predictors to differentiate severe dengue from scrub typhus in children

Background: Objective of study was to compare the clinical features and laboratory parameters at admission and differentiate severe dengue from scrub typhus in children.Methods: Retrospective analysis of case records and comparison of clinical and laboratory parameters at admission of all children with a diagnosis of severe dengue and scrub typhus was done.Results: A total of 72 children were included (severe dengue =40; scrub typhus =32) during the study period. The mean (SD) age of children with severe dengue and scrub typhus was 7.9(3.8) and 11.8(5.8) years, respectively. Majority of children with severe dengue presented with hypotension, 21(52.5%) vs 3(9.4%) in scrub typhus. Children with severe dengue had a relatively low ANC (2.6'1.97x103/mm3 vs 3.9'2.06x103/mm3), low platelet count (50.23'35.55x103/mm3 vs 140'95.0x103/mm3) and low mean ESR at 1hour (8.1'6.82mm vs 33.88'13.79mm) than scrub typhus.Conclusions: Compared to scrub typhus, severe dengue was significantly associated with hypotension, lower ANC, ESR and platelets.

WHO Class of Obesity Influences Functional Recovery Post-TKA

BACKGROUND: No study in the literature has compared early functional recovery following total knee arthroplasty (TKA) in the obese with the nonobese using World Health Organization (WHO) classes of obesity. Our aim was to compare functional scores and flexion post-TKA in each class of obesity as per WHO classification against a matched control group of nonobese patients. METHODS: Records of 885 consecutive primary TKA patients (919 knees) operated by a single surgeon were reviewed. The first 35 knees in each class I, class II and class III obesity group during the study period were then matched with a similar number of knees in nonobese TKA patients during the same period. Functional scores recorded pre- and postoperatively at 3 months and 1 year were Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short-Form Health Survey (SF-12) score, and Knee Society Score (KSS). RESULTS: There was no difference in any parameter between the class I obese and matched nonobese at any assessment point. In the class II obese, as compared to the nonobese, there was no difference in any parameter preoperatively and 3 months postoperatively. However, 1 year postoperatively, the SF-12 physical subscore was lower in the class II obese than the nonobese (44.7 vs. 48.6, p = 0.047) and the WOMAC score was significantly higher (15.8 vs. 9.7, p = 0.04). In the class III obese, the WOMAC score was significantly higher than the nonobese (58.1 vs. 44.3, p < 0.001 preoperatively; 15.7 vs. 8.1, p = 0.005 at 1 year) and KSS was significantly lower (83.5 vs. 96.5, p = 0.049 preoperatively; 172 vs. 185; p = 0.003 at 1 year). Knee flexion was significantly lower in the class III obese than the nonobese (95 vs. 113; p < 0.001 preoperatively; 120 vs. 127; p = 0.002 at 1 year). CONCLUSIONS: The class I obese can expect good early and late functional recovery as the nonobese. The class II obese can expect comparable early functional recovery as the nonobese but their late function may be lesser. The class III obese would have poorer functional scores and lesser knee flexion postoperatively compared to the nonobese. However, compared to their own preoperative status, there is definite improvement in function and knee flexion.

Demystifying the Mystified - An Ambiguous Presentation of Cemento-ossifying Fibroma in Maxilla.

Cemento-ossifying fibroma is a slow growing benign tumor of mesenchymal origin. It is typically found in craniofacial bones, frequently involving the mandible and it tends to occur in third and fourth decade of life with predilection for women. Occurrence of this lesion in maxilla is a rare entity. We report one such case of cemento-ossifying fibroma of size 5x4 cm on upper left maxilla in 38 year old female patient which is an unusual presentation.

Epithelioid Haemangioma – A Diagnostic Dilemma.

Epithelioid haemangioma (EH), synonymously termed as angiolymphoid hyperplasia with eosinophilia, is a rare lesion whose etiopathogenesis is unclear. Clinically it manifests as solitary or multiple nodules in the skin and subcutaneous tissues of the head and neck region. It can also arise in the deep tissues such as muscle, bone and lymphnode. Intra oral involvement is less common and very few cases have been reported in the literature. Common intra oral sites include lip followed by buccal mucosa and tongue. Epithelioid Haemangioma affecting alveolar mucosa is very rare. We report one such case of epithelioid hemangioma of size 4x4 cm on lower right alveolar mucosa in 38 year old female patient.

Addition of Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration and On-Site Cytology to EUS-Guided Fine Needle Biopsy Increases Procedure Time but Not Diagnostic Accuracy

BACKGROUND/AIMS: Although the diagnostic accuracy of endoscopic ultrasound with fine needle aspiration (EUS-FNA) in pancreas adenocarcinoma is high, endoscopic ultrasound with fine needle biopsy (EUS-FNB) is often required in other lesions; in these cases, it may be possible to forgo initial EUS-FNA and rapid on-site cytology evaluation (ROSE). The aim of this study was to compare the diagnostic accuracy of EUS-FNB alone (EUS-FNB group) with a conventional sampling algorithm of EUS-FNA with ROSE followed by EUS-FNB (EUS-FNA/B group) in nonpancreas adenocarcinoma lesions. METHODS: Retrospective cohort study of subjects who underwent EUS sampling of nonpancreatic adenocarcinoma lesions between February 2011 and May 2013. RESULTS: Over the study period, there were 43 lesions biopsied in 41 unique patients in the EUS-FNB group and 53 patients in the EUS-FNA/B group. Overall diagnostic accuracy was similar between the EUS-FNB and EUS-FNA/B groups (83.7% vs. 84.9%; p=1.0). In the subgroup of subepithelial mass lesions, diagnostic accuracy remained similar in the EUS-FNB and EUS-FNA/B groups (81.0% and 70.6%; p=0.7). EUS-FNB procedures were significantly shorter than those in the EUS-FNA/B group (58.4 minutes vs. 73.5 minutes; p<0.0001). CONCLUSIONS: EUS-FNB without on-site cytology provides a high diagnostic accuracy in nonpancreas adenocarcinoma lesions. There appears to be no additive benefit with initial EUS-FNA but this requires further study in a prospective study.

Maternal hormonal interventions as a risk factor for Autism Spectrum Disorder: An epidemiological assessment from India.

Globalization and women empowerment have led to stressful life among Indian women. This stress impairs women’s hormonal makeup and menstrual cycle, leading to infertility. National Family Health Survey-3 (NFHS-3) reports a decline in fertility status in India, indicating a rise in various infertility treatments involving hormonal interventions. No studies are available from India on the risk association link between maternal hormonal treatments and ASD. Hence, this study explores the association of maternal hormonal interventions with risk for ASD. Parents of 942 children (471 ASD and 471 controls) across 9 cities in India participated in the questionnaire-based study. The questionnaire was pilot tested and validated for its content and reliability as a psychometric instrument. Data collection was done at 70 centres through direct interaction with parents and with the help of trained staff. Statistical analysis of data was carried out using SAS 9.1.3. Out of the 471 ASD cases analysed, 58 mothers had undergone hormonal interventions (12.3%) while there were only 22 mothers among controls who underwent hormonal interventions (4.6%). According to logistic regression analysis maternal hormonal intervention (OR=2.24) was a significant risk factor for ASD.

Assessment of Sociodemographic Factors Affecting Immunization Status of Children in Age Group of 12-23 Months in a Rural Area.

Background: Immunization is a powerful and cost effective weapon against vaccine preventable diseases. In India ‘Expanded Programme of Immunization, (EPI) was launched in 1978. But today also immunization coverage in India is comparatively low and far from satisfaction. Objectives: 1. To assess immunization status of children in age group between 12-24 months. 2. To study the sociodemographic factors affecting immunization status. Method : 30*7 cluster sampling method was used to assess sociodemographic factors affecting immunization status of children in age group of 12-23 months in rural area of Beed district (Maharashtra) in India. Results : Out of total 210 children surveyed, 165 (78.57%) were fully immunized, 43(20.48%) were partially immunized and 2(0.95%) were unimmunized. Immunization status of child was found not to be associated with the gender and type of family of child. It was significantly associated with religion, place of birth and availability of immunization card. Immunization status of children went on significantly improving as their mother’s education level increased (p<0.05), but fathers education had no influence. Immunization status of children was found directly related to their socioeconomic class and inversely to birth order. The highest (86.25%) coverage for complete immunization was among the children having birth order II. Immunization status went on decreasing as birth order increased and was the lowest (50.00%) among those having birth order V. Conclusion : To improve immunization coverage in rural area improvement in female literacy and female education is necessary. Similarly improvement in socioeconomic status, limiting the family size and increasing hospital deliveries will lead to improvement in immunization coverage. Also parents should be encouraged to preserve immunization cards of their children as long as possible.

Subcutaneous mucor zygomycosis with potential life-threatening visceral complication.

A mass in right supraclavicular fossa in a diabetic patient mimicking tuberculosis (TB) adenitis that ultimately proved to be subcutaneous zygomycosis. A high degree of clinical suspicion is needed for diagnosis especially when these lesions occur at typical sites for the more common indolent infections like TB. This case is being presented not only because of its rarity, but to emphasize the role of early diagnosis and appropriate treatment to prevent serious complications due to proximity to major structures. Fluconazole was used despite not being the ideal drug, solely due to cost constraints. Our patient responded well. However, we do emphasize that response to fluconazole is the exception rather than the rule.

Aqueous extract of Allium sativum L bulbs offer nephroprotection by attenuating vascular endothelial growth factor and extracellular signal-regulated kinase-1 expression in diabetic rats.

To investigate the nephroprotective effect of garlic and elucidate the mechanism by which it prevents the progression of diabetic nephropathy in diabetic rats, diabetes was induced by a single ip injection of streptozotocin (45 mg/kg body weight). Garlic extract (500 mg/kg body weight) and aminoguanidine (1 g/L) were supplemented in the treatment groups. Histopathological examination using H&E, PAS staining and the immunohistochemical analysis of vascular endothelial growth factor (VEGF) and extracellular signal-regulated kinase-1 (ERK-1) expression were performed on kidney sections at the end of 12 weeks. Significant change in both, the urine and serum biochemistry confirmed kidney damage in diabetic animals which was further confirmed by the histological changes such as mesangial expansion, glomerular basement membrane thickening, glycosuria and proteinuria. However, the diabetic animals treated with garlic extract showed a significant change in urine and serum biochemical parameters such as albumin, urea nitrogen and creatinine compared to that of diabetic rats. Further, the garlic supplemented diabetic rats showed a significant decrease in the expression of VEGF and ERK-1 compared to diabetic rats, attenuating mesangial expansion and glomerulosclerosis. Thus, garlic extract rendered nephroprotection in diabetic rats.

Impact of the RNTCPIRL-EQA-OSE visits on quality of sputum smear microscopy services of Gujarat, India.

Objecu've: On-site evaluation of laboratories with standard checklist is a first step to promote effective and consistent supervision. The present study was carried out to evaluate the impact of the RNTCP- Intermediate Reference Laboratory External Quality Assessment- On-Site Evaluation visits on quality of sputum smear microscopy services of Gujarat, India. Data of three IRL-EQA-OSE visit rounds, carried out between January 2005 and December 2010 are presented here. Materiaf and Methods: Within the Revised National Tuberculosis Control Programme EQA framework, the IRL, Ahmedabad visited all Gujarat District Tuberculosis Centres, and evaluated their sputum smear microscopy services. The study covered a cohort of 29 DTCs during each of the three IRL-EQA-OSE visits. The authors focused on section III of Annexure A to study and analyse the said impact. In order to convert qualitative data into quantitative one, the authors denoted a score of 1 to "Acceptable" (No Error) remark and 0 to "Not-Acceptable" (Error) one. Results.' Alarger degree of improvement was noted in Standard Operating Procedure practices, Disinfection practices, and Internal Quality Control practices. Many DTCs did not retrain their laboratory staff in EQA methodology. The Gujarat DTCs achieved an overall score of (8201957) 86% during the initial OSE visits which consistently improved to (842/957) 88% and (885/957) 92% during the two follow-up OSE visits along with sustenance and improvement in many important laboratory parameters. Conclusion' The co-sponsoring organisation (IRL) recognises the challenges and therefore, is committed to supporting state-level implementation of EQA through additional training, technical assistance to districts, and improving this technical guidance. By periodic IRL. EQA-OSE visits, sputum smear microscopy services can be sustained and improved at field level.

Proficiency panel testing - A reliable tool in external quality assessment of sputum smear microscopy services in Gujarat, India.

Objective: To assess the proficiency of Senior TB Laboratory Supervisors (STLSs) and district level Laboratory Technicians (LTs) in sputum smear microscopy. Method: Intermediate Reference Laboratory (IRL), Ahmedabad had manufactured and validated Proficiency Panel Testing slides from sputum samples, made On Site Evaluation (OSE) visits of District TB Centres (DTCs) in two rounds, and conducted Proficiency Panel Testing of STLSs & DTC-LTs from January 2005 to June 2009. Results: High level of concordance in Z-N smear grading was found between Microbiologist and district laboratory staff. DTC readers reported overall consistency level of more than 98% in Z-N grade agreement during both the IRL, EQA, OSE visits. The tendency to over-grade the panel slides was much higher (more than 22%) as compared to under-grade (less than 2%) them in “correct slides”. High False Positive (HFP) error was not observed in the present study. Conclusion: Laboratory supervisor’s proficiency can be quickly assessed by Proficiency Panel Testing, under multi-level quality assurance network system of sputum smear microscopy in public health programmes like the RNTCP. Proficiency Panel Testing is highly replicable and reproducible tool for quick and reliable assessment of proficiency of the staff and it can be made more effective by raising the proportion of lower grade positive slides in panel set of each reader. DTC readers’ overall agreement level of more than 98% in Z-N grade suggests high level of precision and excellent consistency during both the IRL, EQA, OSE rounds. It is concluded that even for a large network of sputum smear microscopy centres under public health programmes like the RNTCP in order to take corrective action, Proficiency Panel Testing can be effectively used for quick identification of suboptimal- technical performance of the supervisory staff.

Intestinal obstruction due to Basidiobolus ranarum: An unusual case.

A case of intestinal obstruction caused by extensive soft tissue fungal infection of the perineum due to Basidiobolus ranarum is presented here. There was excellent response to antifungal treatment. A literature search revealed the case report of intestinal obstruction due to intrinsic mucosal involvement by the fungus, but extensive soft tissue involvement of the perineum resulting in extraneous obstruction to the rectum, has not been reported so far.

Salivary duct carcinoma: Correlation of morphologic features by fine needle aspiration cytology and histopathology.

Background: Salivary duct carcinoma (SDC) is a highly aggressive primary salivary gland neoplasm that resembles intraductal and infiltrating breast carcinoma. Objectives: To review cytomorphologic features of histology proven SDC and evaluate potential pitfalls in cytologic diagnosis. Materials and Methods: Fine needle aspiration cytology (FNAC) of five histologically proven SDCs were reviewed. Results: One patient was an elderly male (61 years), while the other four patients were younger, in their fourth decade (average age: 38 years). The initial cytologic diagnoses in two of the cases were poorly differentiated carcinoma with differential diagnosis of SDC and high grade mucoepidermoid carcinoma, while in the third case, a possibility of malignant mixed tumor was suggested. In fourth and fifth cases, the diagnosis was suggestive of pleomorphic adenoma with cystic change. The spectrum of cytologic changes included flat sheets and cohesive papillary and three-dimensional clusters. There was moderate to severe nuclear pleomorphism and atypia. Cribriform pattern and necrosis were occasionally identified. Prominent bright granular metachromatic stroma was seen in two of the cases interpreted as pleomorphic adenoma with cystic change and in the tumor reported as suggestive of malignant mixed tumor. The fifth case showed numerous cyst macrophages and apocrine cells with mild nuclear atypia. Conclusion: FNAC of SDC is difficult to interpret because of overlapping cytomorphologic features. Bland cytomorphologic features in some cases and several clinical pitfalls are demonstrated in our series.