Antenatal and postnatal factors associated with neonatal death in the Indian subcontinent: a multilevel analysis.

OBJECTIVES: This study aimed to identify significant antenatal and postnatal factors associated with neonatal death at 2-7 days and at 2-28 days in the Indian subcontinent. Results from this study may help guide strategies to improve antenatal and postnatal care services and reduce neonatal mortality. STUDY DESIGN: Nationally representative recent Demographic and Health Survey data sets from five countries, including Bangladesh, India, Pakistan, Maldives and Nepal, were used. METHODS: Survey-weighted univariate distributions were used for study population characteristics and bivariate distributions, along with the chi-squared test for unadjusted associations. Finally, multilevel logistic regression models were performed to determine the association of antenatal care (ANC) and postnatal care (PNC) factors with neonatal deaths. RESULTS: Among 200,499 live births, the highest neonatal death rate was observed in Pakistan, followed by Bangladesh, whereas the lowest rate was in Nepal. After adjusting for sociodemographic and maternal control variables, the multilevel analysis showed a significantly lower likelihood of neonatal death at 2-7 days and 2-28 days with ANC visits <12 weeks' gestation, at least four ANC visits during pregnancy, PNC visits within the first week after birth and breastfeeding. Delivery at home by a skilled birth attendant compared to unskilled birth attendant was significantly associated with lower neonatal death at 2-7 days. Multifoetal gestation was significantly associated with higher neonatal death at 2-7 days and at 2-28 days. CONCLUSIONS: The findings suggest that strengthening ANC and PNC services will improve newborn health in the Indian subcontinent and decrease neonatal mortality.

A splenic 'cyst': histology confirmed splenic sarcoma.

Primary malignant fibrous histiocytoma, now classified as pleomorphic undifferentiated sarcoma, is the most common soft-tissue sarcoma in adult life. Primary splenic pleomorphic undifferentiated sarcoma is extremely rare and aggressive, and is associated with a poor prognosis; only 14 cases of splenic pleomorphic undifferentiated sarcoma have been documented in the English literature. We discuss a case of a 56-year-old woman with iron-deficiency anaemia, early satiety and left upper-quadrant pain, who was preoperatively diagnosed with a large splenic cyst following thorough investigation. This was excised in an elective procedure. Unfortunately, histology confirmed splenic pleomorphic undifferentiated sarcoma. Following a review and summary of the literature, we discuss key differentials between splenic cysts and splenic pleomorphic undifferentiated sarcoma. This case highlights that iron-deficiency anaemia is unusual in splenic cysts and more sinister causes must be considered.

Effect of resection of localized pancreaticobiliary adenocarcinoma on angiogenic markers and tissue factor related pro-thrombotic and pro-angiogenic activity.

In this study, 52 patients were studied to elucidate the relative impact of resection of localized pancreaticobiliary adenocarcinoma (PBC) on circulating factors of tumour-associated angiogenesis e.g. tissue factor bearing microparticles (TFMP) and vascular endothelial growth factor (VEGF) and their clinicopathological significance to angiogenesis markers in cancer tissue from PBC patients. Angiogenesis array analysis on serum samples revealed that surgical resection of tumour lesion in PBC patients affects the levels of a panel of angiogenesis-related molecules, including VEGF that was verified by ELISA to significantly reduce (median & IQR: 1003(369-2000) vs. 457(159-834) pg/ml; p<0.05). Correspondingly, a significant decrease in the angiogenic activity (decreased capillary tube formation; p<0.05) of serum samples after the surgery was also found. Despite a decrease in number of circulating TFMP after surgery, this did not reach statistical significance; there was a significant reduction in pro-coagulant activity (prolonged prothrombin time, p<0.001) post-operatively. In addition, the activity of total microparticles (MP activity assay, p<0.05) was decreased significantly. Immunohistochemical staining of tumour tissue revealed a strong correlation between the microvessel density (MVD) and VEGF expression. Also, higher levels of circulating TFMP or TF related activity (prothrombin time) correlated significantly with TF expression and MVD on tumour tissues from PBC patients. These findings suggest that in pancreaticobiliary adenocarcinoma TF related angiogenesis drivers are equally significant to VEGF ones, raising the clinical question of whether the effectiveness of angiogenesis targeting studies could be improved through the 'dual' targeting of these pathways in PBC.

Rare benign pathologies mimicking malignancy: A cautionary tale for Whipple's resections.

Benign pathologies demonstrated after a Whipple's resection (pancreatoduodenectomy) for pancreatic and peri-ampullary lesions are relatively uncommon. Here we report two cases where a Whipple's procedure was undertaken for suspected pancreaticobiliary cancer and where the final histology revealed, in each case, a rare benign lesion. The first case confirmed a cholesterol polyp in the distal common bile duct whilst the second case revealed ampullary intramural ectopic gland hyperplasia. Although pre-operative imaging helps in differentiating some benign lesions from malignant lesions, rare benign pathology may still mimic malignant conditions leading to a Whipple's resection.

Case hepatic endometriosis: a continuing diagnostic dilemma.

BACKGROUND: Intraparenchymal endometriosis of liver is rare. It may present as liver tumour and the diagnosis is not usually established till after surgery. CASE OUTLINE: A 48-year-old postmenopausal woman presented with right upper quadrant pain and a cystic liver mass. Liver function tests and tumour markers (alphaFP, CEA, CA 19-9, and CA 125) were normal. Radiological imaging (USS, CT and MRI) suggested a thick walled cystic mass involving segments IV and VIII with complex intracystic septations. Frozen section at operation suggested a benign cystadenoma. The cyst was enucleated using a CUSA (Cavitron ultrasonic aspirator). The final histology confirmed endometriosis. DISCUSSION: Eleven cases of hepatic endometrioma have been reported and only four in postmenopausal women. Preoperative diagnosis poses a challenge and so far none of the cases have been diagnosed preoperatively. Surgery remains the treatment of choice. Accurate diagnosis at time of operation may avoid extensive liver surgery and its associated morbidity.

Hybrid thermoreversible gels from covalent polymers and organogels.

This paper reports on experiments intended for investigating the feasibility of preparing hybrid thermoreversible gels from covalent polymers and noncovalent self-assembling pi-conjugated molecules. The formation and the degree of dispersion of these hybrid gels have been studied with polystyrenes of various tacticities and oligo(p-phenylenevinylene) molecules (OPV) in different nonpolar organic solvents. Detailed investigations of the systems have been carried out by DSC, SAXS, and AFM. It is shown that no liquid-liquid phase separation is involved, indicating that the systems are highly compatible, and that the growth of one type of gel does not interfere with the other. These studies reveal that the resultant hybrid gels are composed of the intermingled fibrillar architectures of both gels.

Anaesthesia for renal transplantation: an update.

SUMMARY: Attempts at organ transplantation have been made since the 19(th) century. Renal transplantation is the preferred treatment for end stage renal disease. Renal transplant anaesthesia requires a thorough understanding of the metabolic and systemic abnormalities in end stage renal disease, familiarity with transplant medicine and expertise in managing and optimizing these patients for the best possible outcome. Also, the associated co-morbid conditions increase the complexity of anaesthesia, pain management and perioperative morbidity and mortality. Hence, a good perioperative management of these patients includes a multidisciplinary collaboration with well-planned anaesthetic strategies.

Fiberoptic Intubation Using LMA as A Conduit and Cook Airway Catheter as An Exchanger in A Case of Tessier 7 Facial Cleft Syndrome.

SUMMARY: Any anaesthesiologist handling a paediatric airway must have a detailed understanding of the differences in airway anatomy, signs and symptoms of airway compromise and common paediatric airway abnormalities. In addition to various equipments needed to manage a difficult airway, there should be a clear plan for evaluation, preparation and management of life threatening complications. We share our experience of successfully managing a difficult airway of a 5 year old child with Tessier 7 facial cleft syndrome. We emphasize the importance of preoperative evaluation, preparation and use of various airway adjuncts.

Renal transplantation-anaesthetic experience of 350 cases.

SUMMARY: Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is the preferred method of treatment for end stage renal disease patients. We describe our experiences through a retrospective analysis of anaesthesia management of 350 cases of both living related and cadaveric renal transplantation conducted between Jan 2004 - April 2008 at Jaslok Hospital And Research Center. Areas of our interest include preoperative patient status, fluid management, hemodynamic stability, anaesthesia management, and perioperative complications. Recent advances in surgical techniques; anaesthesia management and immunosuppressive drugs have made renal transplantation sale and predictable. Preoperative patient optimization, intraoperative physiological stability and postoperative care of renal transplant patients have contributed to the success of renal transplant programme in our hospital.

Quality of life after liver resection for hepatobiliary malignancies.

BACKGROUND: Few prospective longitudinal studies have used a validated quality of life (QOL) instrument in patients undergoing liver resection for hepatobiliary malignancy. METHODS: Patients undergoing liver resection for hepatobiliary tumours in a 1-year period were enrolled. The cancer-specific European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) was completed before operation, and at 6, 12 and 36-48 months after surgery. QOL over time was analysed in relation to several clinical factors. RESULTS: A total of 103 patients were enrolled. Patient compliance was at least 75 per cent at all stages. Most functional scales and the global QOL scale showed a non-significant trend towards deterioration at 6 months and a return to preoperative level at 12 months. Physical functioning and dyspnoea deteriorated significantly at 6 months (P = 0.020 and P = 0.004 respectively) and did not recover by 12 months (P = 0.002 and P < 0.001 respectively). Pain and fatigue showed clinically significant deterioration over 12 months, which was not statistically significant. Survivors without recurrence at 36-48 months showed better QOL than those with recurrent disease. CONCLUSION: Major liver resection is associated with acceptable QOL outcomes, and QOL continues to improve in the long term in those without recurrence.

Triangular and self-triangulating cavocavostomy for orthotopic liver transplantation without posterior suture lines: a modified surgical technique.

A modified caval preservation technique with the potential for decreased incidence of venous outflow obstruction and haemorrhage.

Cystic duct and Heister's "valves".

The anatomy and physiology of the cystic duct have been relatively neglected by anatomists and the function of the spiral mucosal folds or "valves" of Heister, first described in 1732, remains obscure. The gross and microscopic anatomy of the cystic duct is reviewed together with results from laboratory investigations into the function of the cystic duct and its spirally arranged folds. The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man and other animals may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

Liver transplantation for a hilar inflammatory myofibroblastic tumor.

A 7-yr-old boy presented with obstructive jaundice secondary to an inflammatory myofibroblastic tumor centered on the hepatic hilum and extending into the liver. The tumor was further complicated by portal vein phlebitis and occlusion. Attempted resection of the tumor with portal vein reconstruction and bilioenteric drainage was unsuccessful and he required urgent orthotopic liver transplantation. In contrast to more peripheral inflammatory myofibroblastic tumors in the liver, hilar lesions are locally aggressive, causing occlusive portal phlebitis and biliary obstruction. Successful management may include the need for liver transplantation.

Awareness of post-exposure prophylaxis guidelines against occupational exposure to HIV in a Mumbai hospital.

BACKGROUND: Exposure to the human immunodeficiency virus (HIV) is a matter of concern for healthcare workers. We conducted a survey to determine the level of awareness amongst operating room personnel regarding post-exposure prophylaxis in case of needlestick injuries from confirmed or suspected cases of HIV. METHODS: A structured questionnaire was presented to 39 anaesthetists and 31 surgical residents. Questions were related to identification of high risk fluids, risk of transmission, drugs, costs and procedure to be adopted for post-exposure prophylaxis. RESULTS: Fourteen respondents (20%) were aware of the true risk of transmission. About one-third identified all high risk fluids correctly. Fifty-five respondents (78%) correctly stated that washing the site with soap and water was the initial measure, but less than a third knew whom to contact immediately after a needlestick injury. Though 45 respondents (64%) correctly stated that prophylaxis should be initiated within 1 hour of injury, none knew exactly which drugs were to be used. Thirty respondents (42%) were aware of the use of zidovudine but none were aware of the second or third drugs used for post-exposure prophylaxis. Only 4 respondents (6%) knew the correct duration of post-exposure prophylaxis. Five respondents (7%) knew that the drugs were available in medical stores and 7 knew the approximate cost of therapy. CONCLUSION: There is surprisingly poor knowledge of post-exposure prophylaxis against HIV. Ongoing awareness and training programmes are necessary to improve the same.

Interaction of 3-hydroxybenzoate with 3-hydroxybenzoate-6-hydroxylase.

The gradual quenching of the emission fluorescence of 3-HBA in the visible region upon titration with 3-HBA-6-hydroxylase and distinct changes in the near-UV circular dichroic spectrum of the enzyme in the presence of substrate suggest the formation of a stable enzyme-substrate complex. The binding of aromatic substrate 3-hydroxybenzoate to 3-hydroxybenzoate-6-hydroxylase occurs without gross changes in the backbone structure of the enzyme. The binding strength of the ES complex is partially reduced upon chemical modification of arginine, histidine, or tryptophan residues of enzyme, probably implicating their concerted action in the binding of substrate to enzyme. Partial inactivation of enzyme and diminished stability of the ES complex in response to treatment with 1 M urea could be ascribed to localized effects of the denaturant.

Association of the anticancer antibiotic chromomycin A(3) with the nucleosome: role of core histone tail domains in the binding process.

The anticancer antibiotic chromomycin A(3) is a transcription inhibitor which forms two types of complexes with Mg(2+): complex I (1:1 in terms of chromomycin A(3)-Mg(2+)) and complex II (2:1 in terms of chromomycin A(3)-Mg(2+)). These complexes are the DNA-binding ligands. With the broad objective of elucidation of the mechanism for action of this group of transcription inhibitors in eukaryotic systems, we have studied the interaction of the antibiotic with nucleosome core particles under different conditions. We have demonstrated and characterized the role of core histone proteins, particularly the N-terminal tail domains, in the association of nucleosome with both complexes of chromomycin. From a scrutiny of the spectroscopic features of the two bound complexes and comparison of the binding and associated thermodynamic parameters, we have shown the following. Core histone(s) stand(s) in the way of access of the ligand(s) to nucleosomal DNA. N-Terminal intact and chopped core particles interact differentially with the same complex. The modes of interaction of the two complexes, I and II, with the same system are different. Tryptic removal of N-terminal tail domains of core histones enhances the binding potential and access of both complexes of chromomycin to the nucleosomal DNA. Agarose gel electrophoresis of an equilibrium mixture containing either complex I or complex II and a saturating concentration of the core particle has demonstrated that both complexes have a tendency to disrupt the nucleosome structure, leading to a release of nucleosomal DNA. Compared to the N-terminal intact nucleosome, the N-terminal chopped nucleosome is more susceptible to disruption. Therefore, we suggest from the above results that the N-terminal tail domains, which have an important role in eukaryotic gene expression, stand in the way of a free access of external agents such as anticancer drugs to the eukaryotic genome. The significance of the results to understand the molecular basis of the transcription inhibitory capacity of chromomycin is discussed.

Effect of myo-inositol(1,4,5)trisphosphate on the hydrolysis of phytic acid by phytase.

Phytase is a monomeric enzyme of molecular mass 160 kDa which catalyzes the hydrolysis of phytic acid (D-myo inositol hexakisphosphate, InsP6) in a stepwise manner to myo-inositol. The enzyme-InsPn (n = 1-6) interaction at the catalytic site has a dissociation constant in the micro molar range. There also exists in the enzyme, a non-catalytic site specific for InsP3 with dissociation constant in the nano molar range. We have probed the effect of the high affinity InsP3 binding on the dissociation constant (Kd) of the phytase-InsP6 interaction and the kinetics of hydrolysis. These studies demonstrate the effect exerted by the high affinity InsP3 binding on the catalytic site of the enzyme.