Intra-operative fluoroscopic radiation exposure in orthopaedic trauma theatre.

INTRODUCTION: Radiation exposure from intra-operative fluoroscopy in orthopaedic trauma surgery is a common occupational hazard. References for fluoroscopy use in the operating room for commonly performed operations have not been reported adequately. This study aimed to report appropriate intra-operative fluoroscopy use in orthopaedic trauma and compare the effect of surgery type and surgeon grade on radiation exposure. METHODS: Data on 849 cases over an 18-month period were analysed retrospectively. Median and 75th centile values for dose area product (DAP), screening time (ST), and number of fluoroscopy images were calculated for procedures where n > 9 (n = 808). RESULTS: Median DAP for dynamic hip screws for extracapsular femoral neck fractures was 668 mGy/cm2 (ST 36 s), 1040 mGy/cm2 (ST 49 s) for short proximal femoral nail, 1720 mGy/cm2 (ST 2 m 36 s) for long femoral nail for diaphyseal fractures, 25 mGy/cm2 (ST 25 s) for manipulation and Kirschner wire fixation in distal radius fractures, and 27 mGy/cm2 (ST 23 s) for volar locking plate fixation in distal radius fractures. These represented the five commonest procedures performed in the trauma operating room in our hospital. Experienced surgeons utilized less radiation in the operating room than junior surgeons (DAP 90.55 vs. 366.5 mGy/cm2, p = 0.001) and took fewer fluoroscopic images (49 vs. 66, p = 0.008) overall. CONCLUSIONS: This study reports reference values for common trauma operations. These can be utilized by surgeons in the operating room to raise awareness and perform clinical audits of appropriate fluoroscopy use for orthopaedic trauma, using this study as guidance for standards. We demonstrated a significant reduction in fluoroscopy usage with increasing surgeon experience.

Analytical Study of Short- and Long-term Results of Home-based Palliative Care Services to Cancer Patients.

AIMS AND OBJECT: Identification and selection of patients suffering from terminal stage in bed ridden condition upto village level and to determine the type of palliative care need. Also to asses the effectiveness of the palliative care provided at the bed side. MATERIALS: All registered patients under palliative care of Regional Cancer Centre, Agartala from 2014 April to 2016 March. METHODS: A retrospective study. Ten teams comprising of doctors, nurses, pharmacists & Social Workers were trained and engaged in this study for symptom assessment and pain relief of palliative patients. RESULTS: It is highly beneficial for the bed ridden & home bound cancer patients with improved quality of life due to regular home visits and medicine distribution by trained medical personnel. Short term benefits in symptom like pain, nausea & vomiting, retention of urine, constipation, bloating, fever etc. was dramatic after medication by palliative team. Patients also get relief as a result of repeated visit of palliative care team. CONCLUSION: Home based palliative care is beneficial for the bed ridden and home bound chronically ill patients including cancer patients. Bed ridden patients should be cared by palliative care team at least in every week.

Arsenic-Induced Cardiovascular Diseases and their Correlation with Mitochondrial DNA Copy Number, Deletion, and Telomere Length in Bangladeshi Population.

Arsenic contamination is a global health concern, primarily through contaminated groundwater and its entry into the food chain. The association between arsenic exposure and cardiovascular diseases (CVDs) is particularly alarming due to CVDs being the leading cause of death worldwide. Arsenic exposure has also been linked to changes in telomere length, mitochondrial DNA copy number (mtDNAcn), and deletion, further increasing the risk of CVDs. We aimed to determine whether arsenic exposure alters telomere length and mtDNAcn and deletion in a total of 50 CVD patients who underwent open heart surgery hailed from known arsenic-affected and unaffected areas in Bangladesh. Amount of arsenic was determined from the collected nails and cardiac tissues. Relative telomere length and mtDNAcn and deletion were quantified by qRT-PCR. The patients from arsenic-contaminated areas had higher average arsenic deposits in their fingers and toenails (P < 0.05) and higher cardiac tissue injury scores (P < 0.05). Moreover, approximately 1.5-fold shorter telomere length (P < 0.05, r = - 0.775), 1.2-fold decreased mtDNAcn (P < 0.05, r = - 0.797), and an 81-fold higher amount of mitochondrial DNA deletion (P < 0.05, r = 0.784) were observed in the patients who had higher arsenic deposition in their nails. Higher levels of arsenic exposure were found to be linked to shorter telomere length, decreased mtDNAcn, and increased mitochondrial DNA deletion in the patients from As-affected areas. It can also be anticipated that the correlation of arsenic exposure with telomere length, mtDNAcn, and deletion can be used as biomarkers for early diagnosis of arsenic-induced cardiovascular diseases.

Common ocular surface disorders in patients in intensive care units.

Ocular surface disorders are frequently encountered in patients in Intensive Care Units (ICUs). Because of significant impairment of major organs, treatment is focused on the management of organ failures. Therefore, ophthalmological complications are frequently overlooked in this setting. To identify the types and frequencies of ocular surface disorders reported in patients in ICUs, a literature review using the keywords: Intensive Care; Eye care; ICU; ITU; Ophthalmological disorders; Eye disorders was performed. The databases of CINAHL, PUBMED, EMBASE and COCHRANE library were searched. The higher quality papers are summarized in tables with statements of methodology to clarify the level of evidence. The most prevalent ocular disorders identified in ICU patients were exposure keratopathy (3.6% to 60%), chemosis (9% to 80%), and microbial keratitis. Of the various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of moisture chambers or polyethylene covers. Early diagnosis and effective treatment will help to prevent microbial keratitis and visual loss.

Protective effects of Corchorus olitorius and Butea monosperma against Arsenic induced aberrant methylation and mitochondrial DNA damage in wistar rat model.

Millions of people around the world are chronically exposed to Arsenic (As) through food and drinking water. Studies revealed that Arsenic is genotoxic and causes damage to DNA. In this study, we evaluated Corchorus olitorius and Butea monosperma for their alleviative properties against Arsenic induced genotoxicity in vivo using Wistar Rat model. Arsenic exposed rats were given C. olitorius leaf powder and B. monosperma flower powder as supplementation with normal food. Methylation status of p53 promoter was measured using Methylation Sensitive Restriction Endonuclease PCR (MSRE-PCR) assay and mitochondrial DNA (mtDNA) copy number as well as occurrence of a common deletion in mtDNA in liver and kidney tissue was determined through quantitative realtime PCR (qPCR). Arsenic exposed rats after supplementation showed relatively less severe effects of toxicity evident by significantly higher amount of (p<0.05) mtDNA copy number and reduced occurrence of deletion containing mtDNA as well as lower levels of methylation in p53 gene promoter. Histopathological analysis revealed less severe histopathological changes of liver and kidney and normal liver and kidney function parameters in supplemented rats. So, the protective properties of B. monosperma and C. olitorius against Arsenic toxicity is evident in molecular level.

Association of arsenic-induced cardiovascular disease susceptibility with genetic polymorphisms.

Inorganic arsenic (iAs) exposure has been reported to have an impact on cardiovascular diseases (CVD). However, there is not much known about the cardiac tissue injury of CVD patients in relation to iAs exposure and potential role of single nucleotide polymorphisms (SNPs) of genes related to iAs metabolism, oxidative stress, endothelial dysfunction and inflammation which may play important roles in such CVD cases. In this dual center cross-sectional study, based on the exclusion and inclusion criteria, we have recruited 50 patients out of 270, who came from known arsenic-affected and- unaffected areas of mainly Chittagong, Dhaka and Rajshahi divisions of Bangladesh and underwent open-heart surgery at the selected centers during July 2017 to June 2018. We found that the patients from arsenic affected areas contained significantly higher average iAs concentrations in their urine (6.72 ± 0.54 ppb, P = 0.028), nail (529.29 ± 38.76 ppb, P < 0.05) and cardiac tissue (4.83 ± 0.50 ppb, P < 0.05) samples. Patients' age, sex, BMI, hypertension and diabetes status adjusted analysis showed that patients from arsenic-affected areas had significantly higher iAs concentration in cardiac tissue (2.854, 95%CI 1.017-8.012, P = 0.046) reflecting higher cardiac tissue injury among them (1.831, 95%CI 1.032-3.249, P = 0.039), which in turn allowed the analysis to assume that the iAs exposure have played a vital role in patients' disease condition. Adjusted analysis showed significant association between urinary iAs concentration with AA (P = 0.012) and AG (P = 0.034) genotypes and cardiac iAs concentration with AA (P = 0.017) genotype of AS3MT rs10748835. The AG genotype of AS3MT rs10748835 (13.333 95%CI 1.280-138.845, P = 0.013), AA genotype of NOS3 rs3918181 (25.333 95%CI 2.065-310.757, P = 0.002), GG genotype of ICAM1 rs281432 (12.000 95%CI 1.325-108.674, P = 0.010) and AA genotype of SOD2 rs2758331 (13.333 95%CI 1.280-138.845, P = 0.013) were found significantly associated with CVD patients from arsenic-affected areas. Again, adjusted analysis showed significant association of AA genotype of AS3MT rs10748835 with CVD patients from arsenic affected areas. In comparison to the reference genotypes of the selected SNPs, AA of AS3MT 10748835, AG of NOS3 rs3918181 and AC of rs3918188, GG of ICAM1 rs281432, TT of VCAM1 rs3176867, AA of SOD2 rs2758331 and GT of APOE rs405509 significantly increased odds of cardiac tissue injury of CVD patients from arsenic affected areas. The results showed that the selected SNPs played a susceptibility role towards cardiac tissue iAs concentration and injury among CVD patients from iAs affected areas.

Genomic expression analysis by single-cell mRNA differential display of quiescent CD8 T cells from tumour-infiltrating lymphocytes obtained from in vivo liver tumours.

We performed a genomic study combining single-cell mRNA differential display and RNA subtractive hybridization to elucidate CD8 T-cell quiescence/ignorance. By comparing actively maintained quiescent CD8 T cells from liver tumour tumour-infiltrating lymphocytes (TILs) with quiescent T cells at the single-cell level, we identified differentially expressed candidate genes by high-throughput screening and comparative analysis of expressed sequence tags (ESTs). While genes for the T-cell receptor, tumour necrosis factor (TNF) receptor, TNF-related apoptosis inducing ligand (TRAIL) and perforin were down-regulated, key genes such as Tob, transforming growth factor (TGF)-beta, lung Krüpple-like factor (LKLF), Sno-A, Ski, Myc, Ets-2 repressor factor (ERF) and RE1-silencing transcription factor (REST/NRSF) complex were highly expressed in the quiescent TIL CD8 cells. Real-time polymerase chain reaction (PCR) further confirmed these results. A regulation model is proposed for actively maintained quiescence in CD8 T cells, including three components: up-regulation of the TGF-beta pathway, a shift in the MYC web and inhibition of the cell cycle.

Functional and Structural Consequences of Damaging Single Nucleotide Polymorphisms in Human Prostate Cancer Predisposition Gene RNASEL.

A commonly diagnosed cancer, prostate cancer (PrCa), is being regulated by the gene RNASEL previously known as PRCA1 codes for ribonuclease L which is an integral part of interferon regulated system that mediates antiviral and antiproliferative role of the interferons. Both somatic and germline mutations have been implicated to cause prostate cancer. With an array of available Single Nucleotide Polymorphism data on dbSNP this study is designed to sort out functional SNPs in RNASEL by implementing different authentic computational tools such as SIFT, PolyPhen, SNPs&GO, Fathmm, ConSurf, UTRScan, PDBsum, Tm-Align, I-Mutant, and Project HOPE for functional and structural assessment, solvent accessibility, molecular dynamics, and energy minimization study. Among 794 RNASEL SNP entries 124 SNPs were found nonsynonymous from which SIFT predicted 13 nsSNPs as nontolerable whereas PolyPhen-2 predicted 28. SNPs found on the 3' and 5' UTR were also assessed. By analyzing six tools having different perspectives an aggregate result was produced where nine nsSNPs were found to be most likely to exert deleterious effect. 3D models of mutated proteins were generated to determine the functional and structural effect of the mutations on ribonuclease L. The initial findings were reinforced by the results from I-Mutant and Project HOPE as these tools predicted significant structural and functional instability of the mutated proteins. Expasy-ProSit tool defined the mutations to be situated in the functional domains of the protein. Considering previous analysis this study revealed a conclusive result deducing the available SNP data on the database by identifying the most damaging three nsSNP rs151296858 (G59S), rs145415894 (A276V), and rs35896902 (R592H). As such studies involving polymorphisms of RNASEL were none to be found, the results of the current study would certainly be helpful in future prospects concerning prostate cancer in males.

Molecular-docking study of malaria drug target enzyme transketolase in Plasmodium falciparum 3D7 portends the novel approach to its treatment.

BACKGROUND: Malaria has been a major life threatening mosquito borne disease from long since. Unavailability of any effective vaccine and recent emergence of multi drug resistant strains of malaria pathogen Plasmodium falciparum continues to cause persistent deaths in the tropical and sub-tropical region. As a result, demands for new targets for more effective anti-malarial drugs are escalating. Transketolase is an enzyme of the pentose phosphate pathway; a novel pathway which is involved in energy generation and nucleic acid synthesis. Moreover, significant difference in homology between Plasmodium falciparum transketolase (Pftk) and human (Homo sapiens) transketolase makes it a suitable candidate for drug therapy. Our present study is aimed to predict the 3D structure of Plasmodium falciparum transketolase and design an inhibitor against it. RESULTS: The primary and secondary structural features of the protein is calculated by ProtParam and SOPMA respectively which revealed the protein is composed of 43.3 % alpha helix and 33.04 % random coils along with 15.62 % extended strands, 8.04 % beta turns. The three dimensional structure of the transketolase is constructed using homology modeling tool MODELLAR utilizing several available transketolase structures as templates. The structure is then subjected to deep optimization and validated by structure validation tools PROCHECK, VERIFY 3D, ERRAT, QMEAN. The predicted model scored 0.74 for global model reliability in PROCHECK analysis, which ensures the quality of the model. According to VERIFY 3D the predicted model scored 0.77 which determines good environmental profile along with ERRAT score of 78.313 which is below 95 % rejection limit. Protein-protein and residue-residue interaction networks are generated by STRING and RING server respectively. CASTp server was used to analyze active sites and His 109, Asn 108 and His 515 are found to be more positive site to dock the substrate, in addition molecular docking simulation with Autodock vina determined the estimated free energy of molecular binding was of -6.6 kcal/mol for most favorable binding of 6'-Methyl-Thiamin Diphosphate. CONCLUSION: This predicted structure of Pftk will serve first hand in the future development of effective Pftk inhibitors with potential anti-malarial activity. However, this is a preliminary study of designing an inhibitor against Plasmodium falciparum 3D7; the results await justification by in vitro and in vivo experimentations.

A comprehensive immunoinformatics and target site study revealed the corner-stone toward Chikungunya virus treatment.

Recent concerning facts of Chikungunya virus (CHIKV); a Togaviridae family alphavirus has proved this as a worldwide emerging threat which causes Chikungunya fever and devitalizing arthritis. Despite severe outbreaks and lack of antiviral drug, a mere progress has been made regarding to an epitope-based vaccine designed for CHIKV. In this study, we aimed to design an epitope-based vaccine that can trigger a significant immune response as well as to prognosticate inhibitor that can bind with potential drug target sites by using various immunoinformatics and docking simulation tools. Initially, whole proteome of CHIKV was retrieved from database and perused to identify the most immunogenic protein. Structural properties of the selected protein were analyzed. The capacity to induce both humoral and cell-mediated immunity by T cell and B cell were checked for the selected protein. The peptide region spanning 9 amino acids from 397 to 405 and the sequence YYYELYPTM were found as the most potential B cell and T cell epitopes respectively. This peptide could interact with as many as 19 HLAs and showed high population coverage ranging from 69.50% to 84.94%. By using in silico docking techniques the epitope was further assessed for binding against HLA molecules to verify the binding cleft interaction. In addition with this, the allergenicity of the epitopes was also evaluated. In the post therapeutic strategy, three dimensional structure was predicted along with validation and verification that resulted in molecular docking study to identify the potential drug binding sites and suitable therapeutic inhibitor against targeted protein. Finally, pharmacophore study was also performed in quest of seeing potent drug activity. However, this computational epitope-based peptide vaccine designing and target site prediction against CHIKV opens up a new horizon which may be the prospective way in Chikungunya virus research; the results require validation by in vitro and in vivo experiments.

Uncommon ophthalmologic disorders in intensive care unit patients.

Ophthalmologic complications are frequently encountered in intensive care unit (ICU) patients (Grixti et al. Ocul Surf 2012;10(1):26-42). However, eye care is often overlooked in the critical care setting or just limited to the ocular surface because treatment is focussed on the management of organ failures. Lack of awareness about other less common intraocular sight-threatening conditions may have a devastating effect on the patient's vision. To identify specific, frequently missed uncommon ocular disorders in ICU, a literature review using the keywords "Intensive Care," "Eye care," "ITU," "ICU," "Ophthalmological disorders," "Eye disorders" was performed. The databases of CINAHL, PuBMed, EMBASE, and Cochrane library were searched. The higher quality studies are summarized in the table with statements of methodology to clarify the level of evidence. The most prevalent ophthalmologic disorders identified in critically ill subjects include exposure keratopathy, chemosis, and microbial keratitis. In addition, uncommon eye disorders reported in ICU include metastatic endogenous endophthalmitis, acute primary angle closure, ischemic optic neuropathy, pupil abnormalities, vascular occlusions, and rhino-orbital cerebral mucormycosis. Early diagnosis and effective treatment will help to prevent visual loss.

Assessment of acetabular retroversion following long term review of Salter's osteotomy.

Salter's innominate osteotomy may predispose to anterior over-coverage of the acetabulum. Over cover or retroversion has been demonstrated to be a cause of hip pain, impingement and subsequent osteoarthritis. We reviewed the long-term follow up of seventeen skeletally mature hips in sixteen patients who had previously undergone a Salter's osteotomy in childhood. The Salter pelvic osteotomy was performed at a mean average age of 5 years and follow up at a mean average age of 20 years. Patients were assessed by clinical examination for signs of impingement, Harris Hip Score and pelvic radiograph. Acetabular version was evaluated by the relationship between anterior and posterior walls of the acetabulum using templates applied to the pelvic radiograph as described by Hefti. The median acetabular cover averaged 17 degrees of anteversion with 2 patients (12%) demonstrating retroversion, neither of whom, had signs of impingement on examination. The mean average Harris Hip Score was 85 indicating a good outcome at long-term follow-up. We believe acetabular remodelling may occur with age after Salter's innominate osteotomy and have found good results in patients after skeletal maturation. Fears of long-term anterior over-coverage and retroversion with this operation may be unfounded.

Ethnic differences in preoperative function of patients undergoing total knee arthroplasty.

The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important because poor preoperative functional status is related to poor postoperative function. The aim of our study was to compare the preoperative knee function in patients of Asian origin with that of Caucasians living in the same community. We carried out a prospective study of 63 consecutive Asian patients and 63 age- and gender-matched Caucasian patients undergoing total knee arthroplasty. Preoperative Knee Society Clinical Rating System scores were recorded as a separate knee score and knee function score. The mean preoperative knee score in Asian patients was 37.6 compared with 41.5 in Caucasians (p<0.12); this difference was not statistically significant. The mean preoperative knee function score in Asian patients was 32.5 compared with 45.0 in Caucasians (p<0.00015); this difference was highly statistically significant. We conclude that patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function than Caucasians do. Cultural beliefs and social support partially explain this discrepancy, but health care providers must attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function.

Use of re-transfusion versus vacuum drains in primary total hip replacement.

Whilst the use of re-transfusion drains in primary knee arthroplasty has gained acceptance in reducing the requirement for donor blood products postoperatively, their use in total hip arthroplasty remains uncertain. Using two groups of 32 patients, a comparison was made between re-transfusion drains and vacuum drains in primary total hip arthroplasty in one centre and the requirement for postoperative donor blood. No statistically significant difference was found between the groups in terms of blood loss (p=0.51) or requirements for postoperative blood transfusion (p=0.12). The use of re-transfusion drains in primary total hip arthroplasty did not alter the rate of postoperative blood transfusion. (Hip International 2005; 15: 223-5).

MRSA-free elective orthopaedic surgery.A dedicated elective orthopaedic ward free from MRSA Alexandra Hospital, Redditch, UK.

Deep infection complicating arthroplasty surgery carries a heavy financial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at 1 billion per year by the National Audit Office. Healthcare associated infection is an area currently under great scrutiny. The Alexandra Hospital, Redditch, has developed a dedicated elective orthopaedic ward free from methicillin-resistant Staphylococcus aureus (MRSA) that delivers high quality and high volume major joint replacement surgery through rigorous infection control. Between October 2001 and December 2002, the Alexandra Hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005-0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p= 0.01 (CI 0.004- 0.03). The total number of joint replacements performed per year, utilising the same number of elective beds, increased from 482 in 2001 to 629 in 2002. We believe that the MRSA screening policy and subsequent altered bed utilisation have contributed to lowering the rate of infection and improved efficiency. We have developed a safe, effective and efficient orthopaedic unit within the framework of an acute NHS trust. We believe the practical changes and modest investment that have been made within our department can be repeated in other units around the country with relative ease. (Hip International 2005; 15: 171-6).

Early failure modalities in hip resurfacing?

Between 1996 and 2002, we treated 60 patients (65 hips) by hip resurfacing. The notes and radiographs of these cases were studied retrospectively and the modalities of failure identified. At a mean follow-up of 51 months, 14 of these cases (22%) required revision surgery. One patient had died from unrelated causes and one was lost to follow-up. At the time of primary surgery, the mean age of the patients in our series was 55 years. The commonest mechanism of failure in our series was fractured neck of femur (six cases). Four of these occurred in females over the age of 60. None of the fractured necks of femur were associated with trauma. There were four cases of loose acetabular components and one case of progressive AVN (avascular necrosis). Two patients required revision surgery for ongoing hip pain and one required a twostage revision for early deep infection. (Hip International 2005; 15: 155-8).