Effect of the timing of insertion of postpartum intrauterine contraceptive device (PPIUCD) copper T380A on expulsion rates.

Background & objectives: Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications. Methods: This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly's placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates. Results: The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion. Interpretation & conclusions: In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group.

Polymorphisms in vitamin B12 and folate metabolising genes and their association with adverse pregnancy outcome: secondary analysis of a population based case control study.

Vitamin B12 and folate deficiency leads to accumulation of homocysteine that increases the risk of adverse pregnancy outcomes like preterm birth and low birth weight (LBW) of the neonate. We explored the association of genetic variants of key vitamin B12 and folate metabolising enzymes (MTHFR C677T and A1298C, MTR A2756G, TCN-2 C776G) with preterm birth and LBW in South Indian women. MTHFR A1298C heterozygotes (AC) were at higher risk for preterm delivery, whereas TCN-2 C776G heterozygotes (CG) were at higher risk for both preterm delivery and LBW. MTHFR C677T, A1298C and MTR A2756G haplotype CAG was protective for preterm delivery (p=.036, OR = 0.475; 95% CI: 0.233-0.97), whereas, haplotype CCG increasing the risk of preterm birth by 1.8 folds (p=.018, OR = 1.81; 95% CI: 1.09-2.98). These results underscore the significance of vitamin B12 and folate in the pathophysiology of preterm birth and LBW.Impact StatementWhat is already known on this subject? Polymorphisms of vitamin B12 and folate metabolising genes have been reported to influence preterm birth and LBW, but the reports are not consistent.What do the results of this study add? We observed a relationship of MTHFR A1298C and TCN-2 C776G with preterm birth, and significant association of TCN-2 C776G with LBW in infants.What are the implications of these findings for clinical practice and/or further research? Identification of women carrying these polymorphic risk alleles may benefit from early nutritional modifications.

Cross-sectional association between vitamin B12 status and probable postpartum depression in Indian women.

BACKGROUND: Vitamin B12 is an essential micronutrient for neurological function, as it leads to the regeneration of methionine from homocysteine, which is precursor of biologically active molecule S-Adenosyl Methionine (SAM). Pregnancy is a state of increased demand and delayed postpartum repletion of nutrients may predispose women to depression. METHODS: We included women who visited the hospital at 6-weeks postpartum for a regular checkup. Inclusion criteria were age (18-50 years), and willingness to donate venous sample for analysis. Exclusion criteria included previous history of mood disorders or antidepressant medication use, and any systemic illness like hypothyroidism, epilepsy, diabetes, and hypertension. Based on EPDS score of 10 as a cutoff, 217 women with probable postpartum depression (PPD) and equal number of age and BMI matched controls were included. Plasma total vitamin B12, holotranscobalamin (holotc), homocysteine (hcy), methyl malonic acid (MMA), 5-methyl tetrahydrofolate (THF), SAM and serotonin levels were estimated using commercially available ELISA kits. Combined B12 (cB12) score was calculated from study parameters. Multivariate analysis was performed to assess the risk of probable postpartum depression. RESULTS: Total vitamin B12 and combined B12 score were found to be significantly lower (p = 0.001) and MMA (p = 0.002) and 5-methyl THF (p < 0.001) levels were higher in women with probable depression than women without probable PPD. Women in the lowest vitamin B12 quartile had 4.53 times higher likelihood of probable postpartum depression (p < 0.001). Multivariate analysis demonstrated that decreasing vitamin B12 (OR = 0.394; 95% CI: 0.189-0.822) and cB12 (OR = 0.293; 95% CI: 0182-0.470) and increasing MMA (OR = 2.14; 95% CI: 1.63-2.83) and 5-methyl THF levels (OR = 3.29; 95% CI: 1.59-6.83) were significantly associated with the risk of probable PPD. CONCLUSION: Low vitamin B12 may contribute to depressive symptoms in vulnerable postpartum period.

Moriarty's sign - predictor of skin graft take.

BACKGROUND: Resurfacing wound beds with split skin graft is the most common procedure in plastic surgery. Association of more pain in the donor site than in the recipient site has been used as a predictor of successful graft take by Stark in 1962 who termed it Moriartys sign. PURPOSE: The aim of the study was: 1) to predict the successful take of skin graft by eliciting Moriartys sign; 2) to decide the day of first graft inspection based on Moriartys sign. METHODS: The authors hereby present a prospective study in 100 patients who underwent wound resurfacing with split thickness skin graft at the Department of Plastic Surgery in a tertiary care center between January 2014 and June 2015. The area with more pain, absence of pain or equivocal response at the graft donor site was recorded on the visual analog scale for 10 days. RESULTS: In this study, 80 patients had positive Moriartys sign, 12 patients had equivocal responses and 8 patients showed a negative sign. Patients with positive Moriartys sign underwent their first graft inspection on 10th postoperative day and showed 100% graft take. Twelve patients with equivocal response underwent first graft inspection on 5th day and had 70-80% graft take.  In 8 patients, with negative Moriartys sign first graft inspection done on 3rd day, the graft take was < 50%. CONCLUSION: The study demonstrates that Moriartys sign is a reliable clinical predictor of split thickness skin graft take and may be useful as a guide to determine the day of first graft inspection. It is an effective method even for junior members of the surgical and nursing team to monitor parameters in relation to this sign. It can be practiced in a smaller group of hospitals, too. Hence, the authors recommend to integrate this clinical assessment in routine practice.

Dengue virus transmission from live donor liver graft.

Arboviral transmission through transplanted organs is rare. We report a highly probable case of dengue viral transmission during live donor liver transplantation. Fever with severe thrombocytopenia was observed in the donor and recipient within 6 and 9 days after transplantation, respectively. Dengue diagnosis was confirmed by testing blood and explant tissue from the donor and recipient using dengue-specific NAT (nucleic acid testing) and serology. Serology indicated the donor had secondary dengue infection that ran a mild course. However, the dengue illness in the recipient was severe and deteriorated rapidly, eventually proving fatal. The recipient's explant liver tissue tested negative for viral RNA indicative of a pretransplant naïve status. The prM-Envelope gene sequence analysis of the donor and recipient viral RNA identified a similar serotype (DENV1) with almost 100% sequence identity in the envelope region. Molecular phylogenetic analysis of donor and recipient viral envelope sequences with regional and local dengue strains further confirmed their molecular similarity, suggesting a probable donor-to-recipient transmission via organ transplantation. Screening of living donors for dengue virus may be considered in endemic regions.

A Study on Omentin-1 and Prostate Specific Antigen in Women on Treatment for Polycystic Ovary Syndrome.

Omentin-1 and prostate specific antigen (PSA) are known to be markers of insulin resistance and hyperandrogenism respectively in polycystic ovary syndrome (PCOS). This study aimed to assess the changes in serum omentin-1 and PSA levels in PCOS patients while on treatment. Serum omentin-1, PSA, BMI and Ferriman gallwey score (FG score) were measured in 80 women with PCOS. The subjects were treated depending on their presenting complaints. The parameters were analysed at baseline and after 3 months of treatment viz. lifestyle modification (Group I), oral contraceptive pills (OCP) (Group II), clomiphene citrate (Group III), medroxy progesterone acetate (Group IV) or metformin (Group V) and was compared using paired-t test. Group II showed significant increase in serum omentin-1 (271.7 ± 112.2 vs 378.1 ± 242 ng/ml; P = 0.025) and decrease in serum PSA (0.014 ± 0.02 vs 0.005 ± 0.008 ng/ml; P = 0.027) after 3 cycles of OCP. Group I and IV also showed a decrease in serum PSA while FG score decreased in group II and group III. There was a negative correlation observed between serum omentin-1 and BMI. To conclude, PCOS women showed increase in serum omentin-1 levels after 3 cycles of OCP while serum PSA decreased after 3 months of lifestyle modification or on treatment with OCP or medroxy progesterone acetate.

Addition of power Doppler to grey scale transvaginal ultrasonography for improving the prediction of endometrial pathology in perimenopausal women with abnormal uterine bleeding.

BACKGROUND & OBJECTIVES: Transvaginal ultrasonography (TVS) is a non-invasive procedure and can be used as a screening tool among women with abnormal uterine bleeding (AUB). Power Doppler is useful in depicting the vascular architecture better than the conventional Doppler. Hence, this study was conducted to evaluate whether addition of power Doppler to grey scale TVS can replace invasive hysteroscopy for the prediction of endometrial pathology in perimenopausal women with AUB. METHODS: One hundred women (>45 yr) with perimenopausal AUB underwent evaluation with TVS, power Doppler and hysteroscopy-guided biopsy after a detailed history and examination. Histopathology was considered as gold standard and other tools such as grey scale TVS with power Doppler and hysteroscopy were compared with it. RESULTS: Fifty six per cent women had no vascularity on power Doppler. Among those who had vascularity, the vascular patterns noted were single-vessel in 18 per cent, scattered-vessel in 15 per cent and multiple-vessel in 11 per cent. The sensitivity, specificity, positive predictive value and negative predictive value of TVS-endometrial thickness with power Doppler in detecting hyperplasia were 50, 86.5, 13.3 and 97.6 per cent, respectively, whereas the same for hysteroscopy were 100, 97.6, 88.1 and 100 per cent, respectively. INTERPRETATION & CONCLUSIONS: Addition of power Doppler to grey scale TVS improved the specificity and negative predictive value almost comparable to hysteroscopy for evaluation of AUB, but sensitivity and positive predictive value remained poor.

Maternal ascites an independent prognostic factor in severe preeclampsia: a matched cohort study.

BACKGROUND: Preeclampsia is a multi-systemic, multi-organ dysfunction associated with increased maternal and perinatal complications. The presence of maternal ascites, a manifestation of endothelial dysfunction and increased capillary permeability, is shown to be associated with adverse outcomes. We aim to investigate the impact of maternal ascites on pregnancy outcome in women with severe preeclampsia. METHODS: A matched cohort study was conducted in a tertiary care teaching hospital in South India between March 2014 and March 2015. One hundred and twenty-one severe preeclamptic women with ascites formed the study cohort while age-, parity-, and gestational age-matched group of 121 severe preeclamptic women without ascites formed the control. Primary outcome was the composite maternal adverse outcome defined as the development of any of eclampsia, pulmonary edema, renal failure, or disseminated intravascular coagulation (DIC). Secondary outcome was the composite perinatal outcome defined as the occurrence of any of still birth, hypoxic ischemic encephalopathy or early neonatal death. RESULTS: Four maternal deaths occurred in the study group. The rates of pregnancies with composite maternal adverse outcome [42 vs 9% RR 4.6 (95% CI 2.5-8.4)] and composite perinatal adverse outcome [36 vs 17% RR 2.1, (95% CI 1.3-3.3)] were significantly more in ascites group than in control group. After adjusting for other confounding variables, ascites was independently associated with adverse maternal events [adjusted OR 16.40 (95% CI 2.88-93.31)] but not adverse perinatal outcome. CONCLUSION: In women with severe preeclampsia, maternal ascites is an independent risk factor for adverse maternal outcome.

Shared Authentic Leadership in Research Teams: Testing a Multiple Mediation Model.

Research teams face complex leadership and coordination challenges. We propose shared authentic leadership (SAL) as a timely approach to addressing these challenges. Drawing from authentic and functional leadership theories, we posit a multiple mediation model that suggests three mechanisms whereby SAL influences team effectiveness: shared mental models (SMM), team trust, and team coordination. To test our hypotheses, we collected survey data on leadership and teamwork within 142 research teams that recently published an article in a peer-reviewed management journal. The results indicate team coordination represents the primary mediating mechanism accounting for the relationship between SAL and research team effectiveness. While teams with high trust and SMM felt more successful and were more satisfied, they were less successful in publishing in high-impact journals. We also found the four SAL dimensions (i.e., self-awareness, relational transparency, balanced processing, and internalized moral perspective) to associate differently with team effectiveness.

A randomized controlled trial of sublingual misoprostol and intramuscular oxytocin for prevention of postpartum hemorrhage.

PURPOSE: In India, two third of maternal deaths occur in rural areas where there is lack of transportation facilities, lack of refrigeration to store the injectable uterotonic drug such as oxytocin, lack of skilled personnel to administer them and lack of sterile syringes and needles. Hence, this study was conceived to evaluate misoprostol as a safe, effective, easily administered non-parenteral drug in the prevention of postpartum hemorrhage. METHODS: This study was conducted during the period from August 2012 to July 2014. Low risk women with singleton pregnancy at term admitted for vaginal delivery were eligible for the study. A total of 500 women were randomized to two groups, 250 in each group, either to receive 400 mcg misoprostol sublingually or 10 units oxytocin intramuscularly at the delivery of anterior shoulder. Patient factors, labor parameters, blood loss and side effects were noted. RESULTS: The women in both the groups were well matched with respect to age, parity, gestational age and labor parameters. There was statistical significance in the blood loss (p = 0.04) between the two groups. The average blood loss was 70 ml in misoprostol group and 75 ml in oxytocin group. Shivering was the statistically significant side effect (p = 0.004) in the misoprostol group and nausea was the statistically significant side effect (p = 0.003) in the oxytocin group. CONCLUSIONS: Sublingual misoprostol is as effective as intramuscular oxytocin as a prophylactic oxytocic in the active management of third stage of labor for prevention of postpartum hemorrhage.

Comparison of nifedipine and progesterone for maintenance tocolysis after arrested preterm labour.

The aim of our study was to compare the efficacy and safety of nifedipine and progesterone for maintenance tocolysis after arrested preterm labour, in prolonging pregnancy and preventing recurrence of preterm labour. This study was a randomised comparative study conducted on 110 pregnant women with arrested preterm labour, randomised to receive either nifedipine 20 mg Q 8-hourly or progesterone 400 mg daily for maintenance tocolysis. Other than demographic parameters, obstetric parameters like previous history of abortions or preterm deliveries, gestational age, cervical dilatation and effacement, ultrasound measured cervical length at admission, were noted. Outcome measures studied were mean prolongation of pregnancy, mode of delivery, neonatal outcome and side-effects of both the drugs. We found that there was no significant difference in the demographic profile, parity, number of abortions, previous preterm deliveries, gestational age, cervical dilatation and effacement at admission between the two groups. A total of 10% of the patients in the nifedipine group and 61% of the patients in the progesterone group delivered at term (p value 0.000). The mean prolongation of pregnancy in the nifedipine group was 16.63 days and 40.14 days in the progesterone group which was significant (p = 0.000). Neonates in the progesterone group had better birth weight, better Apgar scores at 1 and 5 min, lesser need for ventilation and significantly lesser composite morbidity. Nifedipine was associated significantly with side-effects. We conclude that when compared with nifedipine, progesterone significantly prolongs pregnancy in women with arrested preterm labour with better neonatal outcomes and fewer side-effects.

Torsion of partial cleft of ear lobule.

INTRODUCTION: Torsion is a well-known phenomenon involving organs with long mesentery. Torsion in the ear lobule is rare. Ear lobule is very well vascularized. In cases of partial cleft ear lobule, there is a small segment of lobule inferior to the cleft which is vascularized through the pedicles on either side of the cleft. CASE REPORT: A lady aged 89 years presented with discoloration of the ear lobule. She was diagnosed as having gangrene of the central part of lobule. The segment of the lobule had undergone more than 360° torsion. She underwent debridement of gangrenous part and lobuloplasty. DISCUSSION AND CONCLUSION: In our case laxity of the stretched lobule caused the torsion of the segment followed by gangrene. This rare complication indicates the need for correction of the cleft lobule not only for esthetic purpose, but also for the prevention of torsion.

Molecular pathogenesis of microsatellite instability-high early-stage colorectal adenocarcinoma in India.

OBJECTIVES: The prevalence of microsatellite instability (MSI) subtype among all colon cancers in India is about 30 %, approximately two times more than that of western population suggesting different molecular pathogeneses. METHODS: A NanoString analysis-based Pan cancer differential expression (DE) profile was determined in a primary cohort of early-stage CRC (tumor=10, normal=7), and correlated against MSI status. Using RT-PCR, tumor-specific DE genes were validated in another cohort of MSI-high CRC (n=15). RESULTS: Among the most differentially expressed genes, AXIN2, ETV4, and RNF43 were tumor cell-specific signals, while a set of genes including COL11A1, COMP, INHBA, SPP1, MMP3, TLR2, and others were immune cell-specific signals, that had a differential expression between MSI and MSS groups. When overlapped with The Cancer Genome Atlas (TCGA) studies using the Tumor immune estimation resource tool (TIMER), and protein-protein interaction analysis by STRING.db, these genes were segregated to representative tumor cells and immune cells. On validation, the tumor-specific gene signals were inversely associated with TLR4 expression. CONCLUSIONS: The differential expression distribution of AXIN2, ETV4, and RNF43 among tumor and immune cells, suggests more than one pathological subset in the MSI-H subgroup of early-stage CRC in the Indian population.

TE-array--a high throughput tool to study transposon transcription.

BACKGROUND: Although transposable element (TE) derived DNA accounts for more than half of mammalian genomes and initiates a significant proportion of RNA transcripts, high throughput methods are rarely leveraged specifically to detect expression from interspersed repeats. RESULTS: To characterize the contribution of transposons to mammalian transcriptomes, we developed a custom microarray platform with probes covering known human and mouse transposons in both sense and antisense orientations. We termed this platform the "TE-array" and profiled TE repeat expression in a panel of normal mouse tissues. Validation with nanoString® and RNAseq technologies demonstrated that TE-array is an effective method. Our data show that TE transcription occurs preferentially from the sense strand and is regulated in highly tissue-specific patterns. CONCLUSIONS: Our results are consistent with the hypothesis that transposon RNAs frequently originate within genomic TE units and do not primarily accumulate as a consequence of random 'read-through' from gene promoters. Moreover, we find TE expression is highly dependent on the tissue context. This suggests that TE expression may be related to tissue-specific chromatin states or cellular phenotypes. We anticipate that TE-array will provide a scalable method to characterize transposable element RNAs.

Comparison of administration of single dose ceftriaxone for elective caesarean section before skin incision and after cord clamping in preventing post-operative infectious morbidity.

PURPOSE: To compare the efficacy of ceftriaxone before skin incision and after cord clamping in preventing post-operative infectious morbidity and neonatal outcome in elective caesarean section and to determine the effect of antibiotic prophylaxis before skin incision on neonatal outcome. METHODS: Our study was a randomised controlled trial conducted among 874 women undergoing elective caesarean section from October 2010 to July 2012. These women were randomly categorised into two groups with 437 women in each group. Group 1 received single dose of ceftriaxone 1 g intravenously 15-45 min before skin incision. Group 2 received the antibiotic after cord clamping. Primary outcome measures were maternal post-operative infectious morbidities like surgical site wound infection, febrile morbidity, endometritis, urinary tract infections and neonatal sepsis. Results were analysed using Chi-square test and unpaired t test. RESULTS: Surgical site wound infection occurred in 3 women in group 1 (0.7%) and 6 women in group 2 (1.4%). Fever occurred in 9 women in group 1 (2.1%) and 5 in group 2 (1.1%) with the p value of 0.419, not statistically significant. Urinary tract infection occurred in 9 women in group 1 (2.1%) and 7 women in group 2 (1.6%) with the p value of 0.801. None of the women in either group developed endometritis. About 20 neonates [10 neonates (2.3%) in group 1 and 10 neonates (2.3%) in group 2] required NICU admission after caesarean delivery. The reasons for admission were respiratory distress, prematurity and congenital anomaly. About 0.9% of neonates in group 1 and 1.8% in group 2 developed neonatal sepsis with positive blood culture (p = 0.388). CONCLUSION: Timing of administration of prophylactic antibiotics for elective caesarean section either before skin incision or after cord clamping did not have significant difference in the occurrence of post-operative infectious morbidity. No adverse neonatal outcome was observed in women who received the antibiotic before skin incision.

Degloving injuries of the abdominal wall.

OBJECTIVE: To stress the local, regional and global impact of degloving injuries of abdominal wall based on which the surgeon can design the management protocol. METHOD: A retrospective series of seven cases who met with high velocity run-over accidents between the year 2002 to 2007. All patients were clinically examined and the findings confirmed radiologically, which guided the management. RESULTS: Out of the seven patients treated, six survived. All patients had open degloving injury of abdominal wall and in different areas of the lower limbs, while three had an additional closed degloving in the back, thighs and gluteal regions. All of them had pelvic fractures of various types. Three patients had peritoneal injury, of whom one had additional diaphragmatic injury. None of them had hollow viscus perforation or injury to solid viscera despite the varied severity of injuries to the abdominal wall, pelvic bone and diaphragm. CONCLUSION: Degloving injuries of the abdominal wall are rarely encountered in our practice. The associated morbidity and mortality are very high. However, the prognosis can be improved by successful revival and rehabilitation of these patients, which is possible by early resuscitation, recognition of all bony and soft tissue injuries, early debridement and coverage.

A review of 93 cases of ruptured uterus over a period of 2 years in a tertiary care hospital in South India.

This was a retrospective descriptive study carried out on cases in JIPMER between July 2008 and June 2010 among 32,080 deliveries. The study sample included 93 women who had a ruptured uterus. Outcome variables included maternal characteristics, risk factors, management and complications of ruptured uterus. The incidence of ruptured uterus was 0.28%. Most of these women were multiparous (95%), between 20 and 30 years (82%). The majority had a scarred uterus (77%) and 83% were at term gestation. Among women with a scarred uterus, 57 women (79%) had an unknown uterine scar type and 46 women (64%) had < 18 months' duration from the last caesarean section. A total of 37 women (39.7%) presented with ruptured uterus and a dead fetus. Out of 71 women with previous caesarean section, 46 women (49.4%) were allowed trial of scar and developed a ruptured uterus in hospital. Among women with unscarred uterus, 14 presented with rupture and seven of these women were induced in hospital. Out of the 93 cases, 87% were managed with uterine repair and 12 women underwent hysterectomy. A total of 31 babies were born with good Apgar scores; 48 babies were stillborn. We conclude that the strongest association of ruptured uterus was with previous scarred uterus, multiparity and < 18 months' duration from the last caesarean section. There were no maternal deaths. Maternal morbidity was seen in 17% of cases. Perinatal mortality was 60.6%. As a result of the study, we have implemented changes to improve patients' care.

16S rRNA Methyltransferases as Novel Drug Targets Against Tuberculosis.

Tuberculosis (TB) is an airborne infectious disease caused by Mycobacterium tuberculosis (M.tb) whose natural history traces back to 70,000 years. TB remains a major global health burden. Methylation is a type of post-replication, post-transcriptional and post-translational epi-genetic modification involved in transcription, translation, replication, tissue specific expression, embryonic development, genomic imprinting, genome stability and chromatin structure, protein protein interactions and signal transduction indicating its indispensable role in survival of a pathogen like M.tb. The pathogens use this epigenetic mechanism to develop resistance against certain drug molecules and survive the lethality. Drug resistance has become a major challenge to tackle and also a major concern raised by WHO. Methyltransferases are enzymes that catalyze the methylation of various substrates. None of the current TB targets belong to methyltransferases which provides therapeutic opportunities to develop novel drugs through studying methyltransferases as potential novel targets against TB. Targeting 16S rRNA methyltransferases serves two purposes simultaneously: a) translation inhibition and b) simultaneous elimination of the ability to methylate its substrates hence stopping the emergence of drug resistance strains. There are ~ 40 different rRNA methyltransferases and 13 different 16S rRNA specific methyltransferases which are unexplored and provide a huge opportunity for treatment of TB.

Modified Technique of Pectoralis Major Myocutaneous Flap Inset for Buccal Mucosa Reconstruction.

BACKGROUND: Conventional technique of flap inset in buccal mucosa reconstruction is by direct suturing of cutaneous margin of Pectoralis Major Myocutaneous (PMMC) flap to hard and soft palate mucosa and margin of floor of mouth with simple interrupted sutures. We have done a prospective study of the efficacy of anchoring the upper margin of PMMC flap to the hard palate by a modified method in reconstruction of buccal mucosa defects following tumour excision. This is to prevent disruption of suture line from the mucoperiosteum of hard palate and resultant oro-cutaneous fistula. METHODS: This hospital-based prospective study was carried out in the Department of Plastic Surgery at Bangalore, India for a period of 18 months (2015-2017). Patients (N=48) with buccal mucosa defects requiring reconstruction with PMMC flap either with conventional (n=24) or modified method (n=24) following tumour excision were included. Clinico-demographic profile of the patients including age, gender, size of defect, staging of illness, site and type of reconstruction, disruption of suture margin in the hard palate, development of oro-cutaneous fistula (OCF), day of starting oral feeds, removal of Ryle's tube and post-operative average length of stay in the hospital were recorded. RESULTS: Disruption of suture line in hard palate and Oro-cutaneous fistula were statistically significant in study group in both the variables (P-0.033, P-0.033). The median days on which patients were started with oral clear liquids and removal of Ryle's tube were also statistically significant between study and control groups. Post-operative average length of hospital stay which is the outcome of favourable results in the study group was found to be statistically significant (P-0.021) between the groups. CONCLUSION: Overall, modified technique of anchorage of PMMC flap can be considered as a reliable technique in buccal mucosa reconstruction because of its stability, lower complication rates and shorter length of hospital stay.

Cloning, soluble expression and purification of high yield recombinant hGMCSF in Escherichia coli.

Expression of human granulocyte macrophage colony stimulating factor (hGMCSF), a cytokine of therapeutic importance, as a thioredoxin (TRX) fusion has been investigated in Escherichia coli BL21 (DE3) codon plus cells. The expression of this protein was low when cloned under the T7 promoter without any fusion tags. High yield of GMCSF was achieved (∼88 mg/L of fermentation broth) in the shake flask when the gene was fused to the E. coli TRX gene. The protein was purified using a single step Ni(2+)-NTA affinity chromatography and the column bound fusion tag was removed by on-column cleavage with enterokinase. The recombinant hGMCSF was expressed as a soluble and biologically active protein in E. coli, and upon purification, the final yield was ∼44 mg/L in shake flask with a specific activity of 2.3 × 10(8) U/mg. The results of Western blot and RP-HPLC analyses, along with biological activity using the TF-1 cell line, established the identity of the purified hGMCSF. In this paper, we report the highest yield of hGMCSF expressed in E. coli. The bioreactor study shows that the yield of hGMCSF could be easily scalable with a yield of ∼400 mg/L, opening up new opportunities for large scale production hGMCSF in E. coli.