Restarting LDLT During COVID-19: Early Results After Restructuring

IntroductionLiving-donor liver transplantation (LDLT) has been mostly suspended and deceased-donor living transplantation activity has been considerably reduced because of coronavirus disease 2019 (COVID-19). We modified our protocols and procedures in line with COVID-19 guidelines. Since the restructuring, we have performed 20 LDLTs. Our study reports the outcomes of these cases and demonstrates the feasibility of LDLT during this pandemic.Materials and MethodsThe changes were influenced by experiences and communications from across the globe. A month-long self-imposed moratorium was spent in restructuring the program and implementing new protocols. Twenty LDLTs were performed between April 18 and September 15 using the new protocols. Our experience includes 2 simultaneous liver-kidney transplants, 1 ABO-incompatible LDLT, and 1 pediatric case (age 11 months).ResultsNineteen patients recovered and 1 patient died. We maintained our postoperative immunosuppression protocol without many changes. Major complications were observed in 30% of recipients but none of the donors. One recipient was infected with COVID-19 during the postoperative period. A donor-recipient couple contracted COVID-19 after discharge from the hospital. All patients recovered from COVID-19 and liver enzymes were unaffected.ConclusionThis study represents a microcosm of experience in LDLT during the COVID-19 era. Outcomes of LDLT are not affected by COVID-19 per se, provided that we make necessary changes.     

Weight-bearing radiographs and cone-beam computed tomography examinations in adult acquired flatfoot deformity

BackgroundOptimal characterization of Adult acquired flatfoot deformity (AAFD) on two-dimensional radiograph can be challenging. Weightbearing Cone Beam CT (CBCT) may improve characterization of the three-dimensional (3D) structural details of such dynamic deformity. We compared and validated AAFD measurements between weightbearing radiograph and weightbearing CBCT images.Methods20 patients (20 feet, right/left: 15/5, male/female: 12/8, mean age: 52.2) with clinical diagnosis of flexible AAFD were prospectively recruited and underwent weightbearing dorsoplantar (DP) and lateral radiograph as well as weightbearing CBCT. Two foot and ankle surgeons performed AAFD measurements at parasagittal and axial planes (lateral and DP radiographs, respectively). Intra- and Inter-observer reliabilities were calculated by Intraclass correlation (ICC) and Cohen’s kappa. Mean values of weightbearing radiograph and weightbearing CBCT measurements were also compared.ResultsExcept for medial-cuneiform-first-metatarsal-angle, adequate intra-observer reliability (range:0.61?0.96) was observed for weightbearing radiographic measurements. Moderate to very good interobserver reliability between weightbearing radiograph and weightbearing CBCT measurements were observed for the following measurements: Naviculocuneiform-angle (ICC:0.47), Medial-cuneiform-first-metatarsal-gapping (ICC:0.58), cuboid-to-floor-distance (ICC:0.68), calcaneal-inclination-angle(ICC:0.7), axial Talonavicular-coverage-angle(ICC:0.56), axial Talus-first-metatarsal-angle(ICC:0.62). Comparing weightbearing radiograph and weightbearing CBCT images, statistically significant differences in the mean values of parasagittal talus-first-metatarsal-angle, medial-cuneiform-first-metatarsal-angle, medial-cuneiform-to-floor-distance and navicular-to-floor-distance was observed (P < 0.05).ConclusionModerate to very good correlation was observed between certain weightbearing radiograph and weightbearing CBCT measurements, however, significant difference was observed between a number of AAFD measurements, which suggest that 2D radiographic evaluation could potentially underestimate the severity of AAFD, when compared to 3D weightbearing CT assessment.     

Implantation of parathyroid carcinoma along fine needle aspiration track

Introduction Fine needle aspiration cytology is not a commonly employed diagnostic modality in the diagnosis of parathyroid tumors.Case report A 28 year old lady being followed-up for 5 years after en bloc resection of a parathyroid carcinoma presented with a nodule in the lower neck, away from the parathyroidectomy scar. The 1 cm isolated nodule was located in the muscular and subcutaneous plane and corresponded to the needle track of FNA performed on a neck nodule before the parathyroidectomy. On evaluation, she had mild hypercalcemia and high normal serum parathyroid hormone levels. FNAC and histology including immunohistochemistry for Chromogranin A after local excision of the nodule confirmed the nodule to be a recurrent parathyroid carcinoma along the needle track.Discussion To the best of the authors’ knowledge, this is only the second case of needle track implantation after FNA in parathyroid carcinoma reported to date. This case highlights the risk of engraftment of parathyroid tissue after FNA and cautions against the use of FNA as a preoperative diagnostic modality for the evaluation of parathyroid lesions.Drs. Agarwal and Dhingra have contributed equally, as joint first authors.     

Furlong Hydroxyapatite-Coated Hip Prosthesis vs the Charnley Cemented Hip Prosthesis

We report the results of a prospective trial comparing uncemented Furlong hydroxyapatite-coated total hip arthroplasty and cemented Charnley total hip arthroplasty. One hundred ninety-one patients were allocated into 2 groups depending on their year of birth. One group received a Furlong hydroxyapatite-coated total hip arthroplasty and the other group received a cemented Charnley total hip arthroplasty. At a mean follow-up of 14 years (12-16 years), Harris hip scores showed no difference between the 2 groups. The longitudinal multilevel model analysis shows that the mean slope of the change in the Harris hip score was −0.02 for the Furlong group and −0.05 for the Charnley group; the difference is 0.03 (P = .002). The survival analysis using Kaplan-Meier regression analysis (the log-rank test λ²₁ = 0.031, P = .58) does not show a significant difference between the 2 groups. Overall survival was 93.6% in the Furlong group and 94.8% in the Charnley group.     

Total Thyroidectomy for Benign Thyroid Disorders in an Endemic Region

Total thyroidectomy is increasingly being accepted as a treatment of choice for differentiated thyroid cancer. However, because of presumed increased morbidity associated with this procedure, it is still not considered a viable option for management of benign thyroid disorders. To assess the safety and efficacy of total thyroidectomy for management of benign thyroid disorders, we analyzed our data from 127 total thyroidectomies performed for benign thyroid disorders. Demographic details, biochemical findings, indications for operation, specimen weight, and complications were noted. Among these patients, 52 had a toxic goiter and 75 had a nontoxic goiter. The mean duration of the goiters being present was 6.08 ± 6.06 years (0.9–26.0 years), and the mean weight of the specimens was 136.88 ± 120.68 g. The incidence of occult malignancy was 6.3% (n= 8), and those of permanent hypothyroidism and permanent recurrent laryngeal nerve palsy were 1.6% and 0.8%, respectively. Total thyroidectomy should be considered a treatment of choice for multinodular goiter and Graves' disease in a setting of palpable nodule(s) or ophthalmopathy (or both). It is particularly relevant in endemic regions where patients present with a long-standing, large nodular goiter with virtually no normal thyroid tissue. Reoperation for recurrent goiter in such a setting would be fraught with distressing complications.     

Arcuate-legged Nonpenetrating Vascular Closure Staples (VCS): Early Experience

Vascular closure staples (VCS) provide a novel technique for fashioning vascular anastomoses, allowing a single operator to perform suture-less anastomoses. They may be used primarily or in an adjuvant role. When VCS are compared to a running suture, advantages include the avoidance of intimal damage, platelet aggregation and intimal hyperplasia at the anastomotic suture line, and a shorter time taken to complete the anastomosis. We report our early experience using VCS in an array of vascular anastomoses and conclude that VCS are a useful addition to the vascular surgeon's armamentarium. They help to decrease the time taken to construct an anastomosis, and are particularly useful in an adjuvant setting, complementing conventionally placed sutures.     

Impact of Common Variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 on the Risk of Type 2 Diabetes in 5,164 Indians

OBJECTIVE

Common variants in PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 genes have been shown to be associated with type 2 diabetes in European populations by genome-wide association studies. We have studied the association of common variants in these eight genes with type 2 diabetes and related traits in Indians by combining the data from two independent case–control studies.

RESEARCH DESIGN AND METHODS

We genotyped eight single nucleotide polymorphisms (PPARG-rs1801282, KCNJ11-rs5219, TCF7L2-rs7903146, SLC30A8-rs13266634, HHEX-rs1111875, CDKN2A-rs10811661, IGF2BP2-rs4402960, and CDKAL1-rs10946398) in 5,164 unrelated Indians of Indo-European ethnicity, including 2,486 type 2 diabetic patients and 2,678 ethnically matched control subjects.

RESULTS

We confirmed the association of all eight loci with type 2 diabetes with odds ratio (OR) ranging from 1.18 to 1.89 (P = 1.6 × 10⁻³ to 4.6 × 10⁻³⁴). The strongest association with the highest effect size was observed for TCF7L2 (OR 1.89 [95% CI 1.71–2.09], P = 4.6 × 10⁻³⁴). We also found significant association of PPARG and TCF7L2 with homeostasis model assessment of β-cell function (P = 6.9 × 10⁻⁸ and 3 × 10⁻⁴, respectively), which looked consistent with recessive and under-dominant models, respectively.

CONCLUSIONS

Our study replicates the association of well-established common variants with type 2 diabetes in Indians and shows larger effect size for most of them than those reported in Europeans.Type 2 diabetes is a complex metabolic disorder with both genetic and environmental factors such as food habits and lifestyle contributing to its pathogenesis (1). Due to its complex etiology, the progress of discovery of genetic components for type 2 diabetes had been very slow until the advent of high throughput genome-wide association (GWA) studies (2). Until recently, only a few common variants in PPARG (3), KCNJ11 (4), and TCF7L2 (5) were shown to be associated with type 2 diabetes. With the advent of GWA studies, there are at least 20 loci identified today that are associated with the risk of type 2 diabetes (6). The first GWA study in the French population revealed SLC30A8 and HHEX as new loci for type 2 diabetes in addition to replicating the strong association with TCF7L2 (7). Further, GWA studies added several new genes including CDKAL1, CDKN2A, IGF2BP2, and FTO to the list of type 2 diabetes–associated loci and confirmed the associations for PPARG, KCNJ11, and TCF7L2 (8–12).India harbors the maximum number of diabetic patients, which is projected to double by the year 2030 (13). Indians are diagnosed with diabetes a decade earlier and at a lower BMI than Europeans, which may be partly explained by their excess central obesity (14,15). Hence, determination of genetic risk factors predicting the risk of type 2 diabetes in the Indian population is highly desirable. Recent evidence suggests that the genetic basis of several diseases in Indians might be different from that of Europeans (16,17), which could be due to differences in the risk allele frequency and pattern of linkage disequilibrium. A report from the Indian Genome Variation Consortium also suggested that most of the populations in the Indian subcontinent are distinct from HapMap populations (18). Hence, genes associated with a disease in other populations need to be assessed for their role in the Indian population. The present study evaluated the association of eight most replicated and well-established genetic variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 with type 2 diabetes and related quantitative traits in Indians. We also performed allele dosage analysis of these variants and investigated their influence on quantitative metabolic traits related to type 2 diabetes.     

Effects of correction of metabolic acidosis on blood urea and bone metabolism in patients with mild to moderate chronic kidney disease: a prospective randomized single blind controlled trial

BACKGROUND: There are no controlled trials on the efficacy of oral bicarbonate therapy in patients with mild to moderate chronic kidney disease (CKD). This prospective randomized controlled study was done to evaluate the effects of correction of metabolic acidosis on renal functions and bone metabolism in this group of patients. PATIENTS AND METHODS: Forty patients were randomized to treatment with oral bicarbonate or placebo for a period of 3 months. Investigations at baseline included venous pH, bicarbonate, renal functions, serum iPTH, and bone radiology. The treatment group (Group B) received daily oral sodium bicarbonate therapy at a dose of 1.2 mEq/kg of body weight. Their venous blood pH and bicarbonate levels were estimated weekly to keep blood pH near 7.36 and bicarbonate at 22-26 mEq/L by adjusting the dose of sodium bicarbonate. At the end of 3 months, all the tests were repeated in both groups. RESULTS: After oral bicarbonate therapy (OBT), there was a significant decline in the rise of blood urea level in Group B associated with a sense of well-being in 50% patients. The rise in parathormone (PTH) was six times the baseline value in Group A and only 1.5 times baseline value in Group B, although not statistically significant. There was no significant change in total calcium, phosphorus, alkaline phosphatase, creatinine, total protein, or albumin levels. CONCLUSION: Correction of metabolic acidosis in patients with moderate CKD attenuates the rise in blood urea and PTH, which might prevent the deleterious long-term consequences of secondary hyperparathyroidism.     

Cooperative wireless network control based health and activity monitoring system

A real-time cooperative communication based wireless network is presented for monitoring health and activity of an end-user in their environment. The cooperative communication offers better energy consumption and also an opportunity to aware the current location of a user non-intrusively. The link between mobile sensor node and relay node is dynamically established by using Received Signal Strength Indicator (RSSI) and Link Quality Indicator (LQI) based on adaptive relay selection scheme. The study proposes a Linear Acceleration based Transmission Power Decision Control (LA-TPDC) algorithm to further enhance the energy efficiency of cooperative communication. Further, the occurrences of false alarms are carefully prevented by introducing three stages of sequential warning system. The real-time experiments are carried-out by using the nodes, namely mobile sensor node, relay nodes and a destination node which are indigenously developed by using a CC430 microcontroller integrated with an in-built transceiver at 868 MHz. The wireless node performance characteristics, such as energy consumption, Signal-Noise ratio (SNR), Bit Error Rate (BER), Packet Delivery Ratio (PDR) and transmission offset are evaluated for all the participated nodes. The experimental results observed that the proposed linear acceleration based transmission power decision control algorithm almost doubles the battery life time than energy efficient conventional cooperative communication.     

Amelioration of Endotoxin-Induced Uveitis in Rabbit by Topical Administration of Tacrolimus Proglycosome Nano-Vesicles

This work was aimed to improve the efficacy of tacrolimus in the treatment of endotoxin-induced uveitis (EIU) using propylene glycol modified lipid vesicles termed as proglycosome nano-vesicles (PNVs). PNVs were prepared by modified film hydration method. Experimental uveitis in rabbit eye was induced by an intravitreal injection of 20 μL of the endotoxin solution containing 100 ng of lipopolysaccharide endotoxin. In vivo efficacy of PNVs was determined by studying clinical symptoms of uveitis using slit lamp examination and by quantitatively measuring levels of tumor necrosis factor-alpha, interleukin-6, leukocytes and total proteins in aqueous humor, 24 h after intravitreal injection of endotoxin. Comparison was made with healthy, untreated and tacrolimus solution treated eyes. PNVs developed were nano-sized, deformable and showed sustained release of tacrolimus over period of 12 h. In vivo results indicated statistically significant difference between the effects of PNVs in the treatment of EIU compared to tacrolimus. PNV treatment not only subsides clinical symptoms of uveitis but also prevented breakdown of blood aqueous barrier. Tacrolimus loaded PNVs are potential new topical treatment for uveitis.