Arterial hypoxemia in patients with cirrhosis of liver.

INTRODUCTION: Mild hypoxia has been seen in approximately one third of patients with chronic liver disease. Development of hypoxemia in patients with chronic liver disease, modifies the line of management and worsens the prognosis of the disease. Hence an early detection of hypoxemia in these patients is essential. Hypoxemia results from various causes in patients with chronic liver disease. Hepato pulmonary syndrome is an important cause in a patient with hypoxemia and chronic liver disease. Development of this complication in chronic liver disease indicates a poorer prognosis in these patients. Chronic liver disease is also known to be associated with pulmonary manifestations that affect both the pleural space and lung parenchyma. This study was undertaken to study the prevalence of hypoxemia and assess the prognosis in patients with chronic liver disease. MATERIALS AND METHODS: Fourty three patients aged 18 years and above with evidence of cirrhosis, admitted under the department of Medicine and Gastroenterology, were included in the study. A detailed history was taken and clinical examination were done in all patients. All patients underwent ultrasonography, LFT, biochemical tests and upper gastrointestinal endoscopy to confirm chronic liver disease, portal hypertension and varices, if any chest X-ray, 2-D transthoracic echocardiogram, viral studies and pulmonary function tests. The patients in whom arterial hypoxemia was detected with a positive contrast echocardiogram were considered to have hepato pulmonary syndrome. RESULTS: Six out of the 43 patients (13.9%) included in the study had hypo-xemia. Among these 6 patients with hypoxemia, 3 were found to have contrast enhanced echocardiographic evidence of intra pulmonary vascular dilatations and diagnosed hepato pulmonary syndrome. The other 3 patients had evidence of both, interstitial lung disease and pleural effusion contributing to hypoxemia. The patients with hepato pulmonary syndrome had a significant P (A-a) O2 gradient, died during the study period, indicating a poorer prognosis. CONCLUSIONS: We conclude that identification of hypoxemia and its aetiology in patients with chronic liver disease is essential. Identification of hepato pulmonary syndrome is important, as it carries a poor prognosis in patients with chronic liver disease.

Bilateral additional slips of triceps brachii forming osseo-musculo-fibrous tunnels for ulnar nerves.

Rare additional slips of triceps brachii muscle was found bilaterally in a sixty two year old South Indian male cadaver during routine dissection of upper limb for undergraduate students at Melaka-Manipal Medical College, Manipal University, Manipal, India. On left side, the variant additional muscle slip took origin from the lower part of the medial intermuscular septum about 4 cm proximal to the medial humeral epicondyle. From its origin, the muscle fibres were passing over the ulnar nerve and were joining the triceps muscle to get inserted to the upper surface of olecranon process of ulna. On right side, the additional muscle slip was larger and bulkier and was arising from the lower part of the medial border of the humerus about 4 cm proximal to the medial epicondyle in addition to its attachment to the medial intermuscular septum. On both sides, the additional slips were supplied by twigs from the radial nerve. On both sides, the ulnar nerve was passing between variant additional slip and the lower part of the shaft of the humerus in an osseo-musculo-fibrous tunnel. Such variant additional muscle slips may affect the function of triceps muscle and can lead to snapping of medial head of triceps and ulnar nerve over medial epicondyle and also can dynamically compress the ulnar nerve during the contraction of triceps leading to ulnar neuropathy around the elbow.

Isolation of endophytic bacteria producing the anti-cancer alkaloid camptothecine from Miquelia dentata Bedd. (Icacinaceae).

Camptothecine (CPT), a quinoline alkaloid, is a potent inhibitor of eukaryotic topoisomerase I. Because of this activity, several semi-synthetic derivatives of CPT are in clinical use against ovarian and small lung cancers. Together with its derivatives, CPT is the third largest anti-cancer drug in the world market. CPT is produced by several plant species belonging to the Asterid clade. In the recent past, several studies have reported the production of CPT by endophytic fungal associates of some of these plant species. In this paper, we report the production of CPT by endophytic bacteria isolated from Miquelia dentata Bedd. (Icacinaceae). Besides CPT, the bacteria also produced 9-methoxy CPT (9-MeO-CPT), in culture, independent of the host tissue. The chemical nature of CPT and 9-MeO-CPT was determined by LC-MS and ESI-MS/MS analysis, and was shown to be similar to that produced by the host tissue. One of the bacterial isolates examined, showed indications of attenuation of CPT production through sub-culture. This is the first report of production of CPT by endophytic bacteria. The identity of the bacteria was ascertained by Gram staining and 16s rRNA sequencing. We discuss the possible mechanisms that might be involved in the synthesis of CPT by endophytic bacteria.