Early calcium and phosphorus supplementation in VLBW infants to reduce metabolic bone disease of prematurity: a quality improvement initiative.

OBJECTIVE: To reduce the incidence of metabolic bone disease (MBD) among very low birthweight (VLBW) infants admitted to neonatal intensive care unit from baseline of 35% by 50% over 2 years by implementing a quality improvement (QI) initiative. METHODS: A multidisciplinary QI team used evidence-based interventions and the healthcare improvement model to reduce MBD rate in VLBW infants. The specific interventions included routine enteral supplementation of calcium and phosphorus using Human Milk Fortifier (HMF) to expressed breast milk by day 14 of life (Plan/Do/Study/Act (PDSA) cycle 1), parenteral and early enteral supplementation of calcium and phosphorus (PDSA cycles 2 and 3). We included VLBW infants admitted within the study period at birth and excluded babies with congenital malformations, skeletal disorders and those who died before 2 weeks of age. Compliance with adding HMF by day 14, compliance with adding calcium and phosphorus in total parenteral nutrition (TPN) from day 1 of life and compliance with starting HMF when the baby reached 100 mL/kg/day of feeds were used as process indicators. The incidence of MBD was used as an outcome indicator during the study. The incidence of MBD was tracked using the Statistical Process Control methodology. RESULTS: The baseline MBD rate in 2015 was 35%. After the first PDSA cycle, 20% developed MBD (p=0.02). The same was sustained for a period of 1 year with the rate of 22%. After the second and third PDSA cycles, there was a drop in the MBD rate to 17%, and sustained for 3 months with 21%. CONCLUSION: Implementation of QI initiatives decreased the MBD rate from 35% to <20%. Early parenteral calcium and phosphorus supplementation in TPN and optimising enteral supplementation with multicomponent fortifiers appear to have significant reduction in the incidence of MBD.

Mediastinal parathyroid adenoma removal by video-assisted thoracoscopic surgery.

Ectopic parathyroid adenomas in the mediastinum are rare causes of primary hyperparathyroidism. We report two cases of mediastinal parathyroid adenoma. Functioning parathyroid lesion was localized with the help of nuclear single-photon emission computed tomography scan in both the patients. Video assisted thoracoscopic surgical (VATS) removal of the parathyroid lesions were done. Intraoperative confirmation of parathyroid adenoma was done by frozen section. Further confirmation was done by routine histopathological examination of specimen postoperatively. One patient had left vocal cord paralysis postoperatively. Localization by functional imaging is essential. Minimally invasive methods such as VATS are useful in removing mediastinal parathyroid hyperfunctioning lesions, which carries early postoperative recovery and less complications.

Résumé Les adénomes parathyroïdes ectopiques dans le mediastinum sont des causes rares de l'hyperparathyroïdie primaire. Nous rapportons deux cas d'adénome parathyroïde mediastinal. La lésion parathyroïde de fonctionnement a été localisée avec l'aide du balayage nucléaire de SPECT dans les deux patients. L'enlèvement thoracoscopic aidé vidéo de chirurgie (VATS) des lésions parathyroïdes ont été faits. La confirmation intraopératoire de l'adénome parathyroïde a été faite par section gelée. Une confirmation supplémentaire a été faite par l'examen histopathologique courant du spécimen post opératoirement. Un patient avait laissé la paralysie de corde vocale postopératoirement. La localisation par imagerie fonctionnelle est essentielle. Les méthodes mini-invasives telles que le VATS sont utiles pour enlever les lésions de fonctionnement hyper-médiantinal, qui portent le rétablissement postopératoire tôt et moins de complications.

Community engagement to control dengue and other vector-borne diseases in Alappuzha municipality, Kerala, India.

Introduction Vector-borne diseases (VBDs) are a serious threat in many Indian states, including Kerala. Community-based decentralized planning and engagement are effective strategies that can make positive behavioral changes to control VBDs. Methods This community-based implementation research was conducted during November 2016 - October 2018 in Alappuzha municipality in Kerala, India. It was conducted in two phases. In the first phase, formative research was conducted to know the community's profile and perceptions and thus to plan and develop an appropriate intervention. Baseline data on some entomological indicators were also collected. These data were used to assess the impact of the intervention by comparing with the post-intervention data. In the second phase, an intervention through the community's engagement was implemented in selected wards. The activities included the formation of community committees and the vector control and source reduction activities with the community engagement and inter-sectoral coordination. Results The intervention resulted in a positive change among the community to engage in vector control activities. These efforts along with inter-sectoral coordination resulted in successfully implementing vector source reduction activities. In both wards, pre- and post-intervention entomological data (house index: 16.7 vs 6.0 and 64.2 vs. 8.6; container index: 24.8 vs. 12.1 and 37.7 vs. 18.1; and Breteau index: 21.3 vs. 7.3 and 47.7 vs. 8.6) revealed a considerable vector source reduction. Conclusion The findings of this study suggest considering and including community engagement in public health policy as the main thrust to control VBDs.

Chemopreventive and anti-breast cancer activity of compounds isolated from leaves of Abrus precatorius L.

The present study focuses on isolation and evaluation of the anti-cancer activity of compounds from the leaves of Abrus precatorius. The bioassay-directed strategy was adopted using chromatographic, gas chromatographic-mass spectrum analysis, nuclear magnetic resonance and X-ray crystallography techniques for purification and characterization of active cytotoxic compounds. Further, MDA-MB-231 breast cancer cell lines and 7,12-dimethylbenz (a) anthracene (DMBA) induced virgin female Sprague Dawley (SD) rats were used for in vitro and in vivo cytotoxicity evaluation. Stigmasterol hemihydrate and 9,12-Octadecadienoic acid (Z,Z)-2-hydroxy-1-(hydroxymethyl)ethyl ester or (ß-monolinolein) were the two main cytotoxic constituents of leaf extract of A. precatorius, with an IC50 value of 74.2 and 13.2 µg/ml, respectively, in MDA-MB-231 cells. Additionally, the treatment with the stigmasterol and ß-monolinolein as a combinatorial drug therapy in DMBA-induced female SD rats led to recovery of body weight, decreased tumor weight and volume, without any toxic side effects. Immunohistochemical examination showed extensive cell death and low proliferation in the treated tumor tissues that was confirmed by results from H and E staining, TUNEL assay and Ki-67 index as compared to control animal group. The reversion of glycoprotein, lysosomal and tumor marker enzyme levels back to near-normal levels after treatment with the plant compounds clearly demonstrated the reduction of tumor burden in these animals. This is the first report on isolation and characterization of the two active cytotoxic components from leaves of A. precatorius. Additionally, the profound cytotoxic and tumor-suppressive effect of these two compounds as a combinatorial therapy provide an alternative option for breast cancer treatment.

A Case of Erythroderma Secondary to Hypereosinophilia.

Hypereosinophilic syndrome (HES) is a myeloproliferative disorder characterised by marked peripheral eosinophilia and end organ damage attributable to eosinophilia without secondary cause. Early recognition and treatment are essential to prevent morbidity and mortality. Cytoreduction with Steroids, Hydroxyurea and Imatinib are the main stay of treatment. Molecular studies like Fip1-like-1 fused with platelet derived growth factor receptor alpha (FIP1L1-PDGFRα) etc., are recommended in view of therapeutic implication. In this paper we report a rare case of HES developing in a lady 6 months after surgical removal of lymphangioma of spleen, which in itself is rare.

Cystic Pheochromocytoma Presenting as Adrenal Cyst.

Pheochromocytomas are usually solid tumours. But it can present as cystic lesions in the adrenal gland. Cystic lesions in adrenal gland with hypertension needs attention to rule out pheochromocytoma. If ignored, it may lead to hypertensive emergency, multisystem crisis and death. Early diagnosis with biochemistry, Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) of abdomen, proper functional imaging like Meta Iodo Benzyl Guanidine (MIBG) scan is essential. Proper preoperative preparation is important to prevent hypertensive crisis during and after surgery. We are reporting a case of cystic pheochromocytoma in a young male.

Identification and characterization of a hepcidin from half-smooth tongue sole Cynoglossus semilaevis.

Hepcidin, an antimicrobial peptide, has a dual function including innate immunity and iron regulation. Here, based on the sequence of an EST database, we have isolated and characterized a hepcidin gene (referred to as CsHepcidin) from half-smooth tongue sole (Cynoglossus semilaevis). Analysis of the coding regions indicated CsHepcidin gene comprised 3 exons and 2 introns. The putative CsHepcidin showed a great similarity to other hepcidin orthologues, particularly with respect to its 24 aa signal peptide, typical RX(K/R)R motif and eight conserved cysteine residues in the mature cationic peptide. Phylogenic analysis indicated that CsHepcidin was a hepcidin 1-type peptide of acanthopterygians, with highly homologous with Solea senegalensis hepcidin. In C. semilaevis ontogeny, CsHepcidin mRNA was detected at a low level in unfertilized eggs, increased on 6 d after hatching, and decreased remarkably at metamorphic stage. CsHepcidin transcripts showed a constitutive basal expression in most of the tissues, especially in liver. Challenge with formalin-inactivated Vibrio anguillarum led to significantly up-regulations of CsHepcidin gene in liver, head kidney and spleen in time-dependent manners. Biological activity analysis showed that recombinant CsHEP exhibited direct antimicrobial activity against bacterial pathogens in vitro, particularly showed strong activity against the principal fish pathogens, V. anguillarum and Edwardsiella tarda. All these results suggest that CsHepcidin may be involved in the initial response to invasion of microbial pathogens. Further exploration to elucidate the role of CsHepcidin in iron regulation and embryogenesis in C. semilaevis are needed.