Acute Renal Infarction: An Unusual Cause of Abdominal Pain

Acute renal infarction is an uncommon and under-diagnosed disease. Its clinical presentation is nonspecific and often mimics other more common disease entities. The diagnosis is usually missed or delayed, which frequently results in irreversible renal parenchyma damage. High index of suspicion is required for early diagnosis, as timely intervention may prevent loss of kidney function. We report a case of acute renal infarction following coronary angiography in a patient with paroxysmal atrial fibrillation who initially presented with acute abdominal pain mimicking appendicitis.     

Patient-centered outcomes after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC) is the second most common general surgical operation performed in the United States, yet little has been reported on patient-centered outcomes.

Methods

We prospectively followed 100 patients for 2 years as part of an institutional review board–approved study. The Surgical Outcomes Measurement System (SOMS) was used to quantify quality-of-life (QoL) values at various time points postoperatively.

Results

Maximum pain was reported at 24 h (5.5 ± 2.2), and decreased to preoperative levels at 7 days (1.2 ± 2.3 vs. 2.0 ± 1.6, P = 0.096). Bowel function improved from before the operation to 3 weeks after surgery (10.7 ± 3.8 vs. 12.0 ± 3.2, P < 0.05), but then regressed to preoperative levels. Physical function worsened from before surgery (31.7 ± 6.2) to 1 week (27.5 ± 5.9, P < 0.0001), but surpassed preoperative levels at 3 weeks (33.5 ± 3.4, P < 0.01). Return to the activities of daily living occurred at 6.3 ± 4.7 days and work at 11.1 ± 9.0 days. Fatigue increased from before surgery (15.8 ± 6.2) to week 1 (20.7 ± 6.6, P < 0.0001) before improving at week 3 (14.0 ± 5.8, P < 0.01). Forty-four patients contacted the health care team 61 times before their 3 weeks appointment, most commonly for wound issues (26.2 %), pain (24.6 %), and gastrointestinal issues (24.6 %). Seventy-two percent reported that the procedure had no negative effect on cosmesis at 6 months. Satisfaction with the procedure was high, averaging 9.52 out of 11.

Conclusions

QoL is significantly affected in the 24 h after LC but returns to baseline at week 3. Cosmesis and overall satisfaction are high, and QoL improvements are maintained in the long term except for bowel function, which regresses to preoperative levels of impairment. Analysis of patient-initiated contacts after LC may provide feedback on discharge counseling to increase patient satisfaction.     

Tracheal intubation with size 1 Airtraq in a 3 month old child with occipital meningocele: A novel experience

Meningocele is a neural tube defect where meninges protrude through a skeletal defect. Occipital meningocele compounded with the problems of paediatric airway itself pose challenges to anaesthesiologist in securing and maintaining airway. We present a case report of a 3 month-old-child with occipital meningocele posted for ventriculo-peritoneal shunt for hydrocephalus, who was successfully intubated using a size 1 Airtraq optical laryngoscope.     

In vitro kinetic release study,antimicrobial activity and in vivo toxicity profile of a kojic acid ester-based nanoemulsion for topical application

Nanoemulsions have emerged as novel vehicles for drug delivery that allow sustained or controlled release for topical application. In this study, kojic acid ester-based nanoemulsion (KAE-NA) was analyzed for in vitro permeation evaluation, kinetic release study, in vitro antimicrobial activity and in vivo toxicity profile on embryonic zebrafish (Danio rerio). Based on KAE-NA in vitro permeation evaluation, the percentage of permeation was significantly improved from 4.94% at 1 h to 59.64% at 8 h of application. The permeation rate of KAE-NA at 8 h was 4659.50 μg cm⁻² h⁻¹ (initial concentration, C₀ = 2000 μg mL⁻¹) with a permeability coefficient (K_p) value of 0.48 cm h⁻¹. The kinetic release analysis showed the Korsmeyer–Peppas model was the best fitted kinetic model with high linearity [R² = 0.9964]. Antimicrobial activity of KAE-NA was studied against the skin pathogen bacteria Staphylococcus aureus ATCC 43300. The results indicated that the inhibition zone size of the KAE-NA (8.00 ± 0.0 mm) was slightly bigger than that of its active ingredient, kojic acid ester (6.5 ± 0.0 mm). The toxicity profile of KAE-NA on embryonic zebrafish revealed less toxicity with LC₅₀ (50% lethal concentration) more than 500 μg mL⁻¹. The survival rate of the embryonic zebrafish was more than 80% when treated at doses ranging from 7.81–250 μg mL⁻¹ and showed normal development throughout the experiment without any observed deformation. Hence, KAE-NA proved to be less toxic on the embryonic zebrafish.

Nanoemulsions have emerged as novel vehicles for drug delivery that allow sustained or controlled release for topical application.     

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.     

Carnosic acid ameliorates depressive‐like symptoms along with the modulation of FGF9 in the hippocampus of middle carotid artery occlusion‐induced Sprague Dawley rats

The increased survival rate of stroke patients has led to the higher incidences of post‐stroke depression. Carnosic acid has the ability to cross blood brain barrier with good neuro‐modulatory actions. Recently, inclined level of fibroblast growth factor 9 (FGF9) in the postmortem brain of the depressed patients was noted. Therefore, in the present study, the effect of carnosic acid on post‐stroke depression‐like behavior, and the expression of FGF9 were evaluated. After 3 weeks of middle carotid artery occlusion in Sprague Dawley rats, carnosic acid (20 and 40 mg/kg) was administered for 2 weeks. Sucrose preference test, forced swimming test, and open field test were performed and hippocampi were analyzed for FGF9 and FGFR‐3. In comparison to post‐stroke depressed rats, carnosic acid increased the sucrose preference, and reduced the immobility time of the rats by ~2×. The speed and distance‐covered were also increased. At 40 mg/kg, FGF9 was reduced by ~3× while FGFR‐3/Actin was increased by ~1.5×. Altogether results suggest anti‐depressant‐like activity of carnosic acid in post‐stroke depressed rats with decreased expression of hippocampal FGF9.     

The Target for Statins,HMG-CoA Reductase,Is Expressed in Ductal Carcinoma-In Situ and May Predict Patient Response to Radiotherapy

Background

Patients with ductal carcinoma-in-situ (DCIS) are currently not prescribed adjuvant systemic treatment after surgery and radiotherapy. Prediction of DCIS patients who would benefit from radiotherapy is warranted. Statins have been suggested to exert radio-sensitizing effects. The target for cholesterol-lowering statins is HMG-CoA reductase (HMGCR), the rate-limiting enzyme in the mevalonate pathway. The aim of this study was to examine HMGCR expression in DCIS and study its treatment predictive value.

Methods

A population-based cohort including 458 women diagnosed with primary DCIS between 1986 and 2004 were followed until November 2011 to study long-term survival. Tumor tissue microarrays were constructed, and immunohistochemical analyses were performed to detect cytoplasmic protein expression of HMGCR. The association between DCIS HMGCR expression and invasive breast cancer recurrence-free survival (RFS_inv) and overall survival (OS) was analyzed by Kaplan–Meier curves, log rank test, and Cox proportional hazard analysis.

Results

HMGCR was strongly expressed in 24 % of the assessed DCIS samples, moderately expressed in 46 %, and weakly expressed in 23 %; no expression was detected in 7 % of the samples. During the follow-up time (median 13.8 years), 61 patients were diagnosed with an invasive breast cancer recurrence, and 80 patients died. A crude analysis showed no survival benefit from radiotherapy. However, patients with strong HMGCR expression showed an improved RFS_inv (log rank, p = 0.03) and OS (log rank, p = 0.04) after radiotherapy. No statistically significant interaction was observed for HMGCR and radiotherapy (RFS_inv p = 0.69 and OS p = 0.29).

Conclusions

This study demonstrates HMGCR expression in DCIS and suggests HMGCR as a predictive marker of response to postoperative radiotherapy in DCIS, although the test for interaction was nonsignificant. Future DCIS studies addressing the potential of statin treatment targeting HMGCR are warranted.