From mild to gangrenous cholecystitis, laparoscopic cholecystectomy is safe 24 hours a day.

OBJECTIVES: Laparoscopic cholecystectomy (LC) at night remains controversial. Prior studies have not controlled for disease severity. We analyzed outcomes of LC performed day vs. night while controlling for the Parkland Grading Scale for Cholecystitis (PGS). METHODS: Analysis of the AAST multicenter evaluation of cholecystitis database was performed. Exclusion criteria included non-operative cases, open operations, and missing PGS. Cases were divided based on operation start time. PGS was used to control for disease severity. Outcomes included operative time, use of bailout techniques and complications. RESULTS: Of 759 procedures identified, 16% were nighttime LC. No differences in demographics, comorbidities, physiologic variables and PGS were noted. Operative time (108.6 min vs 105.6), bailout techniques (8.3% vs 7.4%) and complications (9.9% vs 11.3%) were similar between groups. CONCLUSION: Regardless of severity, laparoscopic cholecystectomy is safe 24-h a day. Operations performed at night have a similar complication profile to those performed during the day.

A high throughput spectral image microscopy system.

A high throughput spectral image microscopy system is configured for rapid detection of rare cells in large populations. To overcome flow cytometry rates and use of fluorophore tags, a system architecture integrates sample mechanical handling, signal processors, and optics in a non-confocal version of light absorption and scattering spectroscopic microscopy. Spectral images with native contrast do not require the use of exogeneous stain to render cells with submicron resolution. Structure may be characterized without restriction to cell clusters of differentiation.

Rectal perfusion parameters normalised to tumour-free rectal wall can predict response to neoadjuvant chemoradiotherapy.

AIMS: To evaluate absolute changes in quantitative and semi-quantitative perfusion parameters using a newer approach of comparing these parameters with tumour-free normal rectal wall (i.e., relative/normalised change) in predicting complete pathological response to chemoradiotherapy. MATERIALS AND METHODS: Perfusion parameters measured before and after treatment of 10 patients with histopathologically proven rectal cancer that showed complete treatment response (Group 1) were compared with 10 patients with residual tumour on histopathology following treatment (Group 2). Quantitative perfusion MRI parameters (Ktrans: volume transfer coefficient reflecting vascular permeability, Kep: flux rate constant, Ve: extracellular volume ratio reflecting vascular permeability, integral of area under the curve (IAUC); Toft model) were quantified by manually delineating a region of interest in the upper, mid and lower third of the tumour (1 cm2), in addition similar parameters were obtained from the normal rectal wall at least 1 cm away from the potential resection margin, absolute as well as relative perfusion values normalised to that of the normal rectal wall were evaluated. The differences in absolute and normalised qualitative parameters were compared within each group using paired t-tests and between each group using analysis of variance (ANOVA). RESULTS: Wash-in, wash-out, positive enhancement integral (PEI), Ktrans, IAUC in the complete pathological responders when compared to the adjacent normal rectal wall showed ratios approaching 1, suggesting that rectal perfusion is similar to the adjacent normal rectal wall in complete pathological responders. The difference in the normalised values in the responders and non-responders was statistically significant. CONCLUSION: Perfusion parameters can be used in predicting response to treatment, when normalised to the adjacent normal rectal wall.

Identification and characterization of 20 novel pathogenic variants in 60 unrelated Indian patients with mucopolysaccharidoses type I and type II.

Mucopolysaccharidoses (MPS), a subgroup of lysosomal storage disorders, are caused due to deficiency of specific lysosomal enzyme involved in catabolism of glycosaminoglycans. To date more than 200 pathogenic variants in the alpha-l-iduronidase (IDUA) for MPS I and ∼500 pathogenic variants in the iduronate-2-sulphatase (IDS) for MPS II have been reported worldwide. The mutation spectrum of MPS type I and MPS type II disorders in Indian population is not characterized yet. In this study, we carried out clinical, biochemical, molecular and in silico analyses to establish the mutation spectrum of MPS I and MPS II in the Indian population. We conducted molecular analysis for 60 MPS-affected patients [MPS I (n = 30) (Hurler syndrome = 17, Hurler-Scheie syndrome = 13), and MPS II (n = 30) (severe = 18, attenuated = 12)] and identified a total of 44 [MPS I (n = 22) and MPS II (n = 22)] different pathogenic variants comprising missense, nonsense, frameshift, gross deletions and splice site variants. A total of 20 [MPS I (n = 14), and MPS II (n = 6)] novel pathogenic sequence variants were identified in our patient cohort. We found that 32% of pathogenic variants detected in IDUA were recurrent and 25% in MPS II. This is the first study revealing the mutation spectrum of MPS I and MPS II patients in the Indian population.

Gene therapy for cancer: regulatory considerations for approval.

The rapidly changing field of gene therapy promises a number of innovative treatments for cancer patients. Advances in genetic modification of cancer and immune cells and the use of oncolytic viruses and bacteria have led to numerous clinical trials for cancer therapy, with several progressing to late-stage product development. At the time of this writing, no gene therapy product has been approved by the United States Food and Drug Administration (FDA). Some of the key scientific and regulatory issues include understanding of gene transfer vector biology, safety of vectors in vitro and in animal models, optimum gene transfer, long-term persistence or integration in the host, shedding of a virus and ability to maintain transgene expression in vivo for a desired period of time. Because of the biological complexity of these products, the FDA encourages a flexible, data-driven approach for preclinical safety testing programs. The clinical trial design should be based on the unique features of gene therapy products, and should ensure the safety of enrolled subjects. This article focuses on regulatory considerations for gene therapy product development and also discusses guidance documents that have been published by the FDA.

Nepalese Homebrewed Alcoholic Beverages: Types, Ingredients, and Ethanol Concentration from a Nation Wide Survey.

BACKGROUND: Despite the enormous public health problems related to traditional alcohol consumption practice in Nepal, this area has been ignored and the information at the national level is limited. Thus this study is designed to explore the readily available commonly practiced Nepalese homebrewed alcoholic beverages, the ingredients used and alcohol strength (ethanol concentration). METHODS: This study was carried out as a part of ongoing household survey on "Alcohol consumption practice among married women of reproductive age in Nepal". A total of 284 homebrewed alcoholic beverage (distilled 175, non-distilled:109) samples were collected from the 16 survey districts of Nepal during the period of April to August, 2013. Ethanol percentage was tested in research lab by using standard procedure. RESULTS: Readily available homebrewed alcoholic beverages in practice were mainly of two types "Distilled" (local Raksi) and "Non-distilled" (Jand, Chhyang, Tumba). Rice, wheat, barley, millet, maize, fruits, and pure sugar were the commonly used ingredients to prepare alcohol. Ethanol concentration in homebrewed alcohol was 14.0% (IQR: 10.0-19.0) ranging from 3% to 40% for distilled, and 5.2% (IQR: 3.5-9.8) ranging from 1% to 18.9% for nondistilled. A significant difference (P<0.05) was found in alcohol strength by residence, development regions, types of alcohol, and the ingredients used. CONCLUSIONS: The median concentration of ethanol in readily available home brewed alcoholic beverages in Nepal was more than the strength of factory produced beer. The alcohol strength varies across their types, ingredients used, residence and regions.

Global burden of genetic disease and the role of genetic screening.

It is estimated that 5.3% of newborns will suffer from a genetic disorder, when followed up until the age of 25 years. In developing, as compared to western countries, hemoglobinopathies and glucose-6-phosphate dehydrogenase deficiency have a higher incidence due to severe falciparum malaria in the distant past, and autosomal recessive disorders have a higher frequency due to greater proportion of consanguineous marriages. Chromosomal disorders have a combined frequency of 1 in 153 births, therefore screening for chromosomal disorders is essential, using biochemical markers, ultrasonography, and recently by non-invasive prenatal diagnosis based on cell-free fetal DNA in maternal plasma. Preconceptional counseling should be encouraged. For genetic disorders screening should be carried out, ideally after marriage, but before pregnancy. The disorders to be screened depend upon ethnicity. Metabolic disorders have a high incidence in developing countries due to greater rate of consanguineous marriages. Newborn screening is recommended to reduce the burden of these disorders, as many metabolic disorders can be treated. Hearing and critical congenital heart disease should both be screened in the newborn period.

Predictors and impact of myocardial injury after transcatheter aortic valve replacement: a multicenter registry

BACKGROUND:Cardiac biomarker release signifying myocardial injury post-transcatheter aortic valve replacement (TAVR) is common, yet its clinical impact within a large TAVR cohort receiving differing types of valve and procedural approaches is unknown.OBJECTIVES:This study sought to determine the incidence, clinical impact, and factors associated with cardiac biomarker elevation post TAVR.METHODS:This multicenter study included 1,131 consecutive patients undergoing TAVR with balloon-expandable (58%) or self-expandable (42%) valves. Transfemoral and transapical (TA) approaches were selected in 73.1% and 20.3% of patients, respectively. Creatine kinase-myocardial band (CK-MB) measurements were obtained at baseline and at several time points within the initial 72 h post TAVR. Echocardiography was performed at baseline and at 6- to 12-month follow-up.RESULTS:Overall, 66% of the TAVR population demonstrated some degree of myocardial injury as determined by a rise in CK-MB levels (peak value: 1.6-fold [interquartile range (IQR): 0.9 to 2.8-fold]). A TA approach and major procedural complications were independently associated with higher peak of CK-MB levels (p < 0.01 for all), which translated into impaired systolic left ventricular function at 6 to 12 months post TAVR (p < 0.01). A greater rise in CK-MB levels independently associated with an increased 30-day, late (median of 21 [IQR: 8 to 36] months) overall and cardiovascular mortality (p < 0.001 for all)...

Design and development of an in-line sputtering system and process development of thin film multilayer neutron supermirrors.

Neutron supermirrors and supermirror polarizers are thin film multilayer based devices which are used for reflecting and polarizing neutrons in various neutron based experiments. In the present communication, the in-house development of a 9 m long in-line dc sputtering system has been described which is suitable for deposition of neutron supermirrors on large size (1500 mm × 150 mm) substrates and in large numbers. The optimisation process of deposition of Co and Ti thin film, Co/Ti periodic multilayers, and a-periodic supermirrors have also been described. The system has been used to deposit thin film multilayer supermirror polarizers which show high reflectivity up to a reasonably large critical wavevector transfer of ∼0.06 Å(-1) (corresponding to m = 2.5, i.e., 2.5 times critical wavevector transfer of natural Ni). The computer code for designing these supermirrors has also been developed in-house.

Molecular analyses of novel ASAH1 mutations causing Farber lipogranulomatosis: analyses of exonic splicing enhancer inactivating mutation.

Farber lipogranulomatosis is a rare autosomal recessive lysosomal storage disorder caused by mutations in the ASAH1 gene. In the largest ever study, we identified and characterized ASAH1 mutations from 11 independent Farber disease (FD) families. A total of 13 different mutations were identified including 1 splice, 1 polypyrimidine tract (PPT) deletion and 11 missense mutations. Eleven mutations were exclusive to the Indian population. The IVS6+4A>G splice and IVS5-16delTTTTC PPT deletion mutations resulted in skipping of exon 6 precluding thereby the region responsible for cleavage of enzyme precursor. A missense mutation (p.V198A) resulted in skipping of exon 8 due to inactivation of an exonic splicing enhancer (ESE) element. This is the first report of mutations affecting PPT and ESE in the ASAH1 gene resulting in FD.

The tumor suppressor Caliban regulates DNA damage-induced apoptosis through p53-dependent and -independent activity.

We previously identified Caliban (Clbn) as the Drosophila homolog of human Serologically defined colon cancer antigen 1 gene and demonstrated that it could function as a tumor suppressor in human non-small-cell lung cancer (NSCLC) cells, although its mode of action was unknown. Herein, we identify roles for Clbn in DNA damage response. We generate clbn knockout flies using homologous recombination and demonstrate that they have a heightened sensitivity to irradiation. We show that normal Clbn function facilitates both p53-dependent and -independent DNA damage-induced apoptosis. Clbn coordinates different apoptosis pathways, showing a two-stage upregulation following DNA damage. Clbn has proapoptotic functions, working with both caspase and the proapoptotic gene Hid. Finally, ecotopic expression of clbn(+) in NSCLC cells suppresses tumor formation in athymic nude mice. We conclude that Caliban is a regulator of DNA damage-induced apoptosis, functioning as a tumor suppressor in both p53-dependent and -independent pathways.

Trichohepatoenteric syndrome: founder mutation in asian indians.

Trichohepatoenteric syndrome (THES) is characterized by chronic diarrhea, dysmorphic facies and hair abnormalities. Hepatic involvement varies from no abnormality to cirrhosis and hemochromatosis. Recently, mutations in the tetratricopeptide repeat domain 37 (TTC37) gene were identified to cause THES. The c.2808G>A variation was suggested as a possible founder mutation among the South Asians. We further report 2 unrelated cases of Asian-Indian ethnicity (Gujrati) with THES, wherein targeted mutation analysis revealed the same mutation in homozygous form in both cases. These findings, as well as haplotype analysis, corroborate the founder mutation hypothesis amongst Asian Indo-Pakistani ethnic groups. A restriction enzyme-based method is also described to identify this founder mutation. One of our probands had multiple hepatic hemangiomas, a feature not previously observed in this syndrome.

Esophageal tuberculosis: role of endoscopic ultrasound in diagnosis.

Esophageal involvement by tuberculosis is rare and is commonly secondary to mediastinal lymph nodal involvement. Endoscopic ultrasound (EUS) is a good modality for evaluation of both esophageal wall and mediastinal lymph nodes. The objectives were to study the role of EUS in diagnosing esophageal tuberculosis, to differentiate primary from secondary form, and to assess the response. Retrospective analysis of data over 7 years (i.e. from 2003 to 2009) was used. The study was set in a tertiary care referral institute and focused on patients diagnosed with esophageal tuberculosis. Interventions used included endoscopy, EUS, EUS-FNA (fine needle aspiration) followed by antituberculosis treatment. The main outcome measurements were symptoms, endoscopic features, EUS features, pathological yield, and response to treatment. There were 32 cases of esophageal tuberculosis. The primary symptom was dysphagia, and endoscopy showed ulcers in 18/32 (56.25%) and extrinsic bulge in 20/32 (62.5%) in middle one third of esophagus. EUS showed lymph nodes adjacent to esophageal pathology in all cases. Subcarinal region was the most common site of lymphadenopathy and they were matted, heterogeneous with predominantly hypoechoic center. Histopathology of endoscopic biopsy of ulcers and EUS-FNA of lymph nodes provided the diagnosis of tuberculosis in 27/32 (84.35%). All patients were treated with antitubercular treatment and showed good clinical, endoscopic and endosonographic response. This is a retrospective study, and PCR and culture for Mycobacterium tuberculosis were not done. Esophageal tuberculosis does not appear to be a primary disease and is most likely secondary to mediastinal nodal tuberculosis. A conglomerated mass of heterogeneous with predominantly hypoechoic lymph nodes with intervening hyperechoic strands and foci on EUS appears to be characteristic of mediastinal tuberculosis.

Recombinant macrophage targeted enzyme replacement therapy for Gaucher disease in India.

OBJECTIVE: Gaucher disease in India has been reported only in a few case reports from India. The aim of the study was to assess the response to enzyme replacement therapy in Indian patients with Gaucher disease. DESIGN: Retrospective analysis of patients receiving CHO-derived recombinant macrophage-targetted glucocorebrosidase. SETTING: Five centers from India with experience in treating lysosomal storage disorders. PATIENTS: The diagnosis of Gaucher disease was confirmed by low glucocerebrosidase levels, though it was first made on splenectomy in 8 and on bone marrow examination in 9 patients. Twenty five of 52 patients diagnosed with Gaucher disease (17 Type I, 8 mild Type III) received treatment for >6 months. Indications for treatment included symptomatic anemia, thrombo-cytopenia, organomegaly, bone disease or mild neurological symptoms leading to impairment of quality of life. Patients with significant neurological involvement were excluded. The drug infusions were given intravenously every 15 days. MAIN OUTCOME MEASURES: Hemoglobin, platelet counts, liver and spleen volumes and growth parameters. RESULTS: 22 of the 25 children who survived were analyzed. After 6 months of treatment, the mean (range) increase in hemoglobin was 1.5 (-3.4 to 6.1) g/dL (P=0.01) and in platelet count was 32 x 10(9)/L (-98.5 x 109 to 145.5 x10(9))/L (P=0.02). The mean (range) increase in weight was 3 kg (-5.6 to 10.5) (P=0.04) and in height was 7.1 cm (0 to 26.5) (P=0.0003). Liver size decreased by a mean (range) of 38.5% (- 5.5 to 86.7) (P=0.0003) and the spleen size by 34.8% (0 to 91.7) (P=0.004). All patients had improvement in bone pains and in 2 patients, neurological symptoms improved with others remaining static. CONCLUSIONS: This is the first reported cohort of patients in India reporting our experience with imiglucerase enzyme replacement therapy for treatment of Gaucher Disease in India.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy.

BACKGROUND AND STUDY AIMS: Patients with suspected tuberculosis without pulmonary lesions and with mediastinal lymphadenopathy often pose a diagnostic challenge. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) cytology is an established modality to evaluate mediastinal and abdominal lesions. The aim of the present study was to evaluate the role of EUS-FNA in isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis. METHODS: Consecutive patients suspected of having tuberculosis with isolated mediastinal lymphadenopathy were included in a prospective study. Mediastinal lymphadenopathy was diagnosed on a contrast-enhanced computed tomography scan of the chest. Patients with concomitant lung parenchymal lesions were excluded. Previous attempts to diagnose the etiology of lymphadenopathy had failed in 69 % of patients. EUS-FNA was performed on an outpatient basis under conscious sedation. The sensitivity, specificity, and diagnostic accuracy of EUS-FNA were calculated. RESULTS: A total of 60 consecutive patients (mean age 39.8 years, 58 % males) with mediastinal lymphadenopathy were included. EUS confirmed the presence of mediastinal lymph nodes ranging in size from 8 mm to 40 mm (mean 26 mm) in all patients. EUS-FNA provided an adequate tissue sample in 54 patients during the first examination and repeat EUS-FNA was necessary in six patients. A final diagnosis was obtained by EUS-FNA in 42 patients (tuberculosis in 32, sarcoidosis in six, and Hodgkin's disease in four patients). An additional 14 patients were treated for tuberculosis based on EUS-FNA and clinical features. Mediastinoscopy was required for diagnosis in the remaining four patients. EUS-FNA had an overall diagnostic yield of 93 %, sensitivity of 71 %, specificity of 100 %, and positive predictive value of 100 %. CONCLUSION: EUS-FNA is an accurate, safe, and minimally invasive modality for evaluating isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis in an endemic area with a high prevalence of tuberculosis.

Rhizomelic chondrodysplasia punctata type 1: report of mutations in 3 children from India.

Rhizomelic chondrodysplasia punctata is a rare autosomal recessive disorder characterized by stippled epiphyses and rhizomelic shortening of the long bones. We report 3 subjects of rhizomelic chondrodysplasia punctata from India and the PEX7 mutations identified in them. The common PEX7-L292X allele, whose high frequency is due to a founder effect in the northern European Caucasian population, was not identified in these patients. Instead, 2 novel alleles are described, including 64_65delGC, which was present on a single PEX7 haplotype and could represent a common allele in the Indian population.

Gross echocardiographic underestimation of mitral valve calcification--a near fatal experience.

Acute severe mitral regurgitation is a feared complication following percutaneous balloon mitral valvuloplasty (PBMV) for the treatment of severe mitral stenosis, contributing to the 1% peri-procedural mortality rate of this procedure. Whilst there is an extensive experience with the use of the Wilkins echocardiographic score to assess patient suitability and predict long-term clinical outcomes following PBMV, catastrophic severe acute mitral regurgitation, such as that described in our patient, is a remarkably rare occurrence following PBMV in patients with favourable Wilkins echocardiographic criteria. We highlight a case of the gross underestimation of the degree of valvular calcification using trans-oesophageal echocardiography, when compared to the findings at surgery, which contributed to our patients' life-threatening mitral regurgitation following the first balloon inflation. We advocate further research into the utility of multi-detector computed tomography (MDCT) imaging for the adjunctive pre-procedural assessment of the degree mitral calcification in order to further minimise the risk of peri-procedural complications associated with PBMV. This would be particularly suitable in the elderly population who normally have greater degrees of valvular calcification that may be underestimated with echocardiography alone.