Management of upper limb arterial injury without angiography--Chennai experience

We present our experience and observations in the management of upper limb arterial injury in a tertiary trauma care centre of a University Hospital in a developing country from January 2000 to January 2002. In this retrospective study, we had treated 27 patients (identified from trauma register) with upper extremity vascular injuries. Clinical examination and Doppler pressure studies were our prime modalities of investigation. Angiography was not employed. Our immediate limb salvage rate was 100%. Two patients developed complications during a mean follow up of 70 days with one requiring amputation. We thereby emphasise the fact that good results can be obtained by thorough clinical examination and Doppler evaluation and prompt surgery without the need for angiography in upper limb vascular trauma.     

Perforation of Jejunal Diverticula in Steroids and Nonsteroidal Anti-Inflammatory Drug Abusers: A Case Series

INTRODUCTION: Jejunal diverticula are rare lesions, and when complications arise, they pose diagnostic difficulties. Perforation is a common complication resulting in an acute abdomen, although preoperative diagnosis is usually not possible. The "gold standard" for management for patients with complications is surgery. We present a series of patients with perforated jejunal diverticula who were on prolonged treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids for Chikungunya fever. METHODS: There were a total of six patients, all of them presenting with perforative peritonitis, with or without shock. Plain abdominal radiogram and ultrasonogram confirmed this, although the exact site of the perforation was not diagnosed preoperatively. All patients underwent exploratory laparotomy and perforated jejunal diverticulum was found. Resection and anastomosis was performed in all cases. RESULTS: The mean operating time was 113.5 minutes, and the blood loss was not significant. Postoperative course was uneventful except wound infection in two patients. There was no mortality. CONCLUSIONS: Prolonged NSAID and steroid use are known to cause ulceration/perforation of the upper digestive tract and colonic diverticula. This seems to be the most likely cause for the perforation of jejunal diverticula in our series of patients. This view is supported by the absence of inflammation and infiltration of neutrophils on histopathological examination of the diverticula.     

Solid self-nanoemulsifying drug delivery system (S-SNEDDS) containing phosphatidylcholine for enhanced bioavailability of highly lipophilic bioactive carotenoid lutein

The objectives of this study was to prepare solid self-nanoemulsifying drug delivery system (S-SNEDDS) containing phosphatidylcholine (PC), an endogenous phospholipid with excellent in vivo solubilization capacity, as oil phase for the delivery of bioactive carotenoid lutein, by spray drying the SNEDDS (liquid system) containing PC using colloidal silica (Aerosil® 200 VV Pharma) as the inert solid carrier, and to evaluate the enhanced bioavailability (BA) of lutein from S-SNEDDS. The droplet size analyses revealed droplet size of less than 100 nm. The solid state characterization of S-SNEDDS by SEM, DSC, and XRPD revealed the absence of crystalline lutein in the S-SNEDDS. The bioavailability study performed in rabbits resulted in enhanced values of C_max and AUC for S-SNEDDS. The enhancement of C_max for S-SNEDDS was about 21-folds and 8-folds compared with lutein powder (LP) and commercial product (CP), respectively. The relative BA of S-SNEDDS compared with CP or LP was 2.74-folds or 11.79-folds, respectively. These results demonstrated excellent ability of S-SNEDDS containing PC as oil phase to enhance the BA of lutein in rabbits. Thus, S-SNEDDS containing PC as oil phase could be a useful lipid drug delivery system for enhancing the BA of lutein in vivo.     

Left Ventricular Lateral Annulus and Left Atrial Free‐Wall Velocity Time Integral Indicate Thromboembolism in Patients with Rheumatic Atrial Fibrillation

Background: Low wall motion and stasis increase the likelihood of clot formation. We hypothesized that tissue Doppler indices of left atrial (LA) motion are reduced in the presence of LA thrombi and may be predictive for clot formation in patients with atrial fibrillation (AF). Methods: We did an observational study for 3 years in 118 patients with rheumatic mitral valve disease in chronic AF who had not received anticoagulation, with (Group 1, n = 36) and without (Group 2, n = 82) thromboembolism. Pulsed tissue Doppler systolic velocities and velocity time integrals (VTIs) were measured in all four chambers. A mean LA VTI was calculated. LA strain during ventricular systole was calculated using VTI and distance between two LA locations. Results: Logistic regression analysis showed that, after adjusting for age, gender, diabetes, hypertension, LA size, and left ventricular (LV) ejection fraction, mean LA VTI [Odds ratio (OR) 0.69, 95%CI (0.56–0.86, P = 0.03)] and lateral mitral annulus VTI [OR 0.15 (0.04–0.56, P = 0.03)] were associated with clot formation. The addition of these two parameters to the conventional risk factors increased the ability to predict thromboembolism (Nagelkerke R²= 0.32–0.50, P = 0.01; area under the curve 0.83 by receiver operating characteristic analysis, P = 0.01). LA strain also had potential to indicate clot formation (0.9 ± 13.8 vs. ?8.2 ± 15.1%, group 1 vs. 2, respectively, P = 0.01). Conclusion: Patients with chronic AF and thromboembolism have reduced LA and LV motion independently of LA size and LV ejection fraction. Tissue Doppler parameters may have potential to predict clot formation in these patients. (Echocardiography 2010;27:1038‐1048)     

Bilateral macular hemorrhage caused by azathioprine-induced aplastic anemia in a corneal graft recipient

PURPOSE: To report the occurrence of bilateral macular hemorrhage following the use of azathioprine for immunosuppression in a corneal transplant recipient. METHODS: The patient underwent therapeutic penetrating keratoplasty for progressive fungal keratitis in his left eye. Although the infection did not recur, the graft failed with vascularization of the cornea in three quadrants. He underwent repeat penetrating keratoplasty 2 years later and was treated with azathioprine (100 mg daily) to enhance graft survival. Four months after instituting azathioprine therapy, he developed aplastic anemia and macular hemorrhage in both eyes. RESULTS: Fluorescein angiography revealed a preretinal location of the macular hemorrhage. After cessation of azathioprine therapy and treatment with blood component replacement, hematological parameters improved and the macular hemorrhage cleared with good visual recovery during the next 2 months. CONCLUSION: This report highlights the serious ocular and systemic complications that can occur following the use of systemic immunosuppressants after ophthalmic surgery.     

PABP2 polyalanine tract expansion causes intranuclear inclusions in oculopharyngeal muscular dystrophy

Oculopharyngeal muscular dystrophy is caused by expansion of a (GCG)n trinucleotide repeat in the poly(A) binding protein 2 (PABP2) gene. The pathological hallmark of oculopharyngeal muscular dystrophy is the accumulation of intranuclear inclusions in muscle fibers. To test whether the polyalanine expansion of PABP2 directly leads to the formation of the nuclear aggregates, both normal and expanded PABP2 cDNAs were expressed in COS-7 cells. We find that expression of mutated PABP2 protein is sufficient for its accumulation as intranuclear inclusions.     

Renal cell carcinoma in children

Summary 2 cases of renal cell carcinoma in children were seen at JIPMER and General Hospital, Pondicherry, in the last 12 years. The first case came late with extensive metastases locally and to the liver, and after nephrectomy died soon with recurrence. The second case after nephrectomy is doing well for one year. Renal cell carcinoma should be considered in the differential diagnosis of renal tumours in children. The course and prognosis is very variable and seems to depend upon histological characteristics. From the departments of Surgery and Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 6.     

Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy

BACKGROUND AND METHOD: This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random-effects model for dichotomous and continuous outcomes respectively. RESULTS: Three trials met the inclusion criteria and all were of poor methodological quality. Complete remission of haemorrhoidal symptoms was better after haemorrhoidectomy (RR 1.68 (95 per cent c.i 1.00 to 2.83)). There was significant heterogeneity between the studies (I(2) = 90.5 per cent; P < 0.001). Fewer patients required retreatment after haemorrhoidectomy (RR 0.20 (95 per cent c.i 0.09 to 0.40)), but anal stenosis, postoperative haemorrhage and incontinence to flatus were more common with this operation. CONCLUSIONS: Haemorrhoidectomy produced better long-term symptom control in patients with grade III haemorrhoids, but was associated with more postoperative complications than RBL.