Lipidomic profiling before and after Roux-en-Y gastric bypass in obese patients with diabetes.

Bariatric surgery is a well-established approach to improve metabolic disease in morbidly obese patients with high cardiovascular risk. The post-operative normalization of lipid metabolism has a central role in the prevention of future cardiovascular events. The aim of the present study therefore was to characterize changes of plasma lipidomic patterns, consisting of 229 lipid species of 13 lipid classes, 3 months after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients with and without diabetes. RYGB resulted in a 15-32% decrease of body mass index, which was associated with a significant reduction of total cholesterol (TC, -28.3%; P=0.02), LDL-cholesterol (LDL-C, -26.8%; P=0.03) and triglycerides (TGs, -63.0%; P=0.05) measured by routine clinical chemistry. HDL-cholesterol remained unchanged. The effect of RYGB on the plasma lipidomic profile was characterized by significant decreases of 87 lipid species from triacylglycerides (TAGs), cholesterol esters (CholEs), lysophosphatidylcholines (LPCs), phosphatidylcholines (PCs), phosphatidylethanolamine ethers (PEOs), phosphatidylinositols (PIs) and ceramides (Cers). The total of plasma lipid components exhibited a substantial decline of 32.6% and 66 lipid species showed a decrease by over 50%. A direct correlation with HbA1C values could be demonstrated for 24 individual lipid species (10 TAG, three CholE, two LPC, one lysophosphatidylcholine ethers (LPCO) (LPC ether), one PC, two phosphatidylcholine ethers (PCO) and five Cer). Notably, two lipid species (TAG 58:5 and PEO 40:5) were inversely correlated with HbA1C. LPCO, as single whole lipid class, was directly related to HbA1C. These data indicate that RYGB-induced modulation of lipidomic profiles provides important information about post-operative metabolic adaptations and might substantially contribute to improvements of glycemic control. These striking changes in the human plasma lipidome may explain acute, weight independent and long-term effects of RYGB on the cardiovascular system, mental status and immune regulation.

Lack of evidence of hepatitis E virus infection among renal transplant recipients in a disease-endemic area.

Persistent hepatitis E virus (HEV) infection has been reported among solid-organ transplant recipients in nonendemic areas. Such chronic infections have all been related to genotype 3 HEV, which is prevalent in these areas. Whether persistent infection occurs with genotype 1 HEV, prevalent in areas where the infection is hyperendemic, is unclear. We therefore tested sera from renal transplant recipients receiving immunosuppressive agents in India, where genotype 1 HEV infection is endemic, for alanine aminotransferase levels, and presence of IgM and IgG anti-HEV antibodies and HEV RNA. Of the 205 subjects studied [aged 16-65 (median, 38) years, 182 male], 46 (22.4%) had abnormal ALT levels (>40 IU/mL). IgG anti-HEV was detected in 52 (20.5%) and IgM anti-HEV was detected in 14 (6.8%) subjects, including four who had IgG anti-HEV; antibody positivity had no relation with serum ALT or serum creatinine. All the sera tested were negative for HEV RNA. These findings suggest that chronic infection with genotype 1 HEV is infrequent.

Why mental health services in low- and middle-income countries are under-resourced, underperforming: an indian perspective.

The inadequacies of mental health services in low- and middleincome countries are often attributed to inadequate allocation of resources. This may not be entirely true. The experience in India suggests that a top-down approach to planning, divorced from the ground realities, poor governance, managerial incompetence and unrealistic expectations from low-paid/poorly motivated primary healthcare personnel play an important role and may result in the failure of even adequately funded programmes. The ambitious National Mental Health Programme (NMHP), launched in 1983 and aimed at providing basic mental health services through the existing primary healthcare system, using the Bellary model, failed to achieve any of its targets over the subsequent decades. In early 2001, the NMHP was radically revamped. It was re-launched as part of the Tenth Five-Year Plan (2002-07) and the budgetary allocation was increased more than 7-fold. However, the programme faltered due to techno-managerial underperformance and the initial momentum was lost. The reasons for this failure are analysed and possible remedial strategies suggested. While the experience documented in the paper is country-specific and relates to India, it may hold useful lessons for other low- and middle-income countries.

Natural history of solitary cerebral cysticercosis cases after albendazole therapy: a longitudinal follow-up study from India.

OBJECTIVES: To find out natural course of solitary cerebral cysticercosis (SCC) cases after treating them with 2 weeks albendazole therapy. MATERIAL AND METHODS: All patients with SCC were treated with 2 weeks of albendazole therapy with follow-up radiological scan at 6 months and 2 years. The evolution of lesion was noted as complete resolution, calcification or persistent active. Antiepileptic drugs (AED) prophylaxis was given for 1 year in patients with complete resolution and for 2 years in calcified lesion, respectively. AED was continued in persistent lesion group till it became calcified or resoluted completely. One-year follow-up was done in all after stopping AED. RESULTS: Among 345 cases, 226 (65.5%) had complete resolution with very low seizure relapse rate with 1 year of seizure free period on AED treatment. On the contrary, 105 (30.5%) had calcified lesion with high seizure relapse rate after stopping AED treatment with 2 years of seizure free period. Fourteen patients (4%) could not stop their antiepileptic medication at all because of active lesion. CONCLUSION: Two-third of patients with SCC have favorable outcome with complete resolution and needs short-term AED prophylaxis and the rest one-third requires long AED treatment to prevent seizures.

Two-tier system of epilepsy evaluation: a useful method for developing countries.

PURPOSE: To test the usefulness of a simplified and clinically oriented, the Epidemiological Classification (EC), in determination of seizure types and appropriate drug selection in epileptic patients at the primary care level. METHODS: The EC was applied to all epileptic patients over 5 years then compared with the currently recommended international classifications of seizures and epilepsy (ICES/ICEES). RESULTS: A total of 1176 patients were enrolled with 2:1 male preponderance and 88% had onset of disease below 30 years of age. Based on EC, 682 (58%) had partial, 333 (28.3%) had generalized and 161 (13.7%) had undetermined seizures semiology. When ICES was applied, seizure typing was same in 86.2%, 68.5% and 26.7% patients of partial, generalized and unclassified seizures respectively. About 87% patients in generalized and partial seizure semiology had no change in selected antiepileptic drug even after the ICES, but 53.6% patients in undetermined group had change in selected AED. Only, 146 patients (12.5%) found to have symptomatic cause for seizure(s) on applying the EC system. After utilizing the ICEES on 1030 patients (87.5%) of "unknown etiology" cases after the EC system, almost 86.5% patients could be classified to a definite etiological class. CONCLUSION: The EC was found useful for determination of seizure type and appropriate AEDs selection at the primary care level. The ICES/ICEES works better at the tertiary care level. This "two-tier" system can be more effective for overall epilepsy management in developing countries with limited facilities.

Leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia.

The adipocyte-derived hormone leptin is an important regulator of appetite and energy expenditure and is now appreciated for its ability to control innate and adaptive immune responses. We have reported previously that the leptin-deficient ob/ob mouse exhibited increased susceptibility to the Gram-negative bacterium Klebsiella pneumoniae. In this report we assessed the impact of chronic leptin deficiency, using ob/ob mice, on pneumococcal pneumonia and examined whether restoring circulating leptin to physiological levels in vivo could improve host defences against this pathogen. We observed that ob/ob mice, compared with wild-type (WT) animals, exhibited enhanced lethality and reduced pulmonary bacterial clearance following Streptococcus pneumoniae challenge. These impairments in host defence in ob/ob mice were associated with elevated levels of lung tumour necrosis factor (TNF)-alpha, macrophage inflammatory peptide (MIP)-2 [correction added after online publication 28 September 2007: definition of MIP corrected], prostaglandin E(2) (PGE(2)), lung neutrophil polymorphonuclear leukocyte (PMN) counts, defective alveolar macrophage (AM) phagocytosis and PMN killing of S. pneumoniae in vitro. Exogenous leptin administration to ob/ob mice in vivo improved survival and greatly improved pulmonary bacterial clearance, reduced bacteraemia, reconstituted AM phagocytosis and PMN H(2)O(2) production and killing of S. pneumoniae in vitro. Our results demonstrate, for the first time, that leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia. Further investigations are warranted to determine whether there is a potential therapeutic role for this adipokine in immunocompromised patients.

Extra-pontine myelinolysis secondary to hypernatremia induced by postpartum water restriction.

A young adult female with restricted water intake during the postpartum period presented with history of progressive weakness, dizziness and tendency to fall with generalized slowing of movement. On examination, patient was anaemic, febrile and stuporous. Investigations revealed hypernatremia, delta waves in electroencephalogram (EEG) and features suggestive of extra-pontine myelinolysis on magnetic resonance imaging (MRI) of brain. After correcting hypernatremia and instituting anti-cholinergic therapy, there was a gradual but steady improvement in neurological symptoms of the patient over a period of one week and the patient was discharged in a conscious, oriented and ambulant state. As such, neuroimaging findings can be crucial in diagnosing hypernatremic encephalopathy in the postpartum period.

Iron (III) complexation with 2,3-pyridinediol.

Iron(III) complexation with 2,3-pyridinediol has been investigated with a view to ascertaining the structures of the complexes formed and examining the analytical potential of this biochemically important ligand.

Laparoscopic surgery in hepatic hydatid cysts: a technical improvement.

Hepatic hydatid cysts are a common surgical problem that is encountered in many tropical countries, including India. Open surgical exploration and excision had been the mainstay of treatment until the advent of laparoscopy. In 1998, we successfully managed six cases of large hepatic hydatid cysts using the videoendoscope, with excellent postoperative follow-up results. Four men and two women participated in this study, with patient ages ranging from 28 to 42 years. The duration of the disease ranged from 1.3 to 2.8 years. All patients had undergone preoperative albendazole therapy for more than 2 months. Complete evacuation of the cyst contents, including all daughter cysts and laminated membrane, along with a subtotal excision of the extrahepatic part of the cyst wall, was accomplished without any spillage into the peritoneal cavity. The saucerized cavity was drained. The drains were removed 6 to 9.4 days after a check ultrasound. Postoperative follow-up ranged from 3 to 9 months and revealed no evidence of a recurrence in the abdomen. It is possible with carefully planned placement of trocars to completely eliminate the risk of spillage, and therefore not compromise the standard principles of hydatid surgery.

Gastroscopic-assisted laparoscopic cystogastrostomy in the management of pseudocysts of the pancreas.

Once pancreatic pseudocysts become persistent, unresolving, and symptomatic, surgical drainage is mandatory. Between January 1998 and December 2001, we performed five laparoscopic cystogastrostomies for such pseudocysts with the simultaneous use of the gastroendoscope. The mean cyst diameter was 20 cm (range, 18.5-24). In the first four cases, the anterior wall of the stomach was entered through two 10-mm balloon cannulae under gastroscopic guidance. By introducing the laparoscope through one port and a harmonic scalpel through the other, a wide cystogastrostomy was performed. In the fifth case, a modification of the above technique was carried out. A single 10-mm cannula was used to enter the stomach and, with the use of a side-viewing gastroduodenoscope as the camera source, the harmonic scalpel was used to create the cystogastrostomy. The punctures in the wall of the stomach were repaired with endosutures. The gallbladder was removed in all cases. The mean operating time was 110 minutes (range, 92-128) for the combined procedure. There were no postoperative complications, and the mean hospital stay was 4 days. Postoperative follow-up with ultrasonography over a period of 1 year in each case revealed complete resolution of the cyst. Laparoscopic cystogastrostomy using harmonic scalpel under gastroscopic control is an effective and rapid method of surgically managing such lesions.

A new homotriterpene from the roots of Marsdenia tenacissima Wight and Arn.

A new homotriterpene isolated from the roots of Marsdenia tenacissima Wight et Arn. has been characterized as 13-(31,32-dimethyl-30-methylene-21alpha-acetoxytetradecanyl)-29-methyl-perhydrophenanthr-1,3-diene on the basis of spectral analyses.

Clinical, radiological and neurophysiological spectrum of JEV encephalitis and other non-specific encephalitis during post-monsoon period in India.

AIMS: To study the spectrum of encephalitis during the post-monsoon period in a tertiary care centre of India. METHODS: Clinical, neurophysiological and radiological features of patients with encephalitis are reported in this communication. The patients were subjected to clinical examination, CT or MRI scan, EEG, motor and somatosensory evoked potentials in both upper and lower limbs bilaterally and concentric needle electromyography. The laboratory studies for Japanese encephalitis (JE) comprised virus isolated, IgM capture ELISA, mercaptoethanol test and hemagglutination inhibition titre in paired sera against JE virus. Patients were classified into JEV encephalitis and non-specific encephalitis. On the basis of radiological features, they were classified into group I (thalamic or basal ganglia involvement), group II (brainstem involvement only) and group III (normal MRI). The outcome was defined into poor (bedridden), partial (dependent for daily activities) and complete (independent) recovery at the end of 3 months. RESULTS: Out of 26 patients (Age 7-70 years, mean 24.8 years), laboratory evidences of JEV infection was present in 14 patients and one patient had herpes simplex encephalitis. The patients with JEV encephalitis had more severe illness as evidenced by lower GCS score, higher frequency of anterior horn cell involvement, movement disorders and more extensive MRI changes. The EEG and MEP changes were also more frequently abnormal in the JEV group. On radiology, 15 patients had thalamic or basal ganglia involvement (group I), 3 isolated midbrain involvement (group II) and 8 had normal MRI (group III). Laboratory evidence consistent with JE were present in 11 out of 12 patients in group I and 3 out of 8 in group III, however, there was no laboratory evidence of JE virus infection in patients with isolated brainstem involvement. There was overlap in the neurologic and systemic manifestations in all the 3 radiological groups as well as in the groups with and without laboratory evidences of JEV infection. CONCLUSION: The observed overlap in neurological and systemic involvement in different subgroups of encephalitis may be due to JE or JE-like viral infection. The possibility of strain variation, change in virulence of organism or immunity of host needs further studies.

ANNUAL HEALTH INCIDENCE.

The 'Report on the Health of the Armed Forces' and the 'Annual Report on the Health of the Army' are documents that contain very useful information. There is, however, a surprising lack of awareness about the data contained within and hence a total absence of critical comment. The average length of stay in respect of certain illnesses, even those like common cold, showed wide disparity between various groups and these facts are a matter of clinical concern and managerial introspection. The reasons for this may lie in the situational content of the publications and the mindset of the readers.

BRIEF HOSPITALIZATION : RESULTS OF TWO-YEAR FOLLOW UP.

Brief hospitalization contributes to quicker and more effective recovery in psychiatric practice. It also leads to a progressive change in the pattern of mental morbidity. Two-year follow-up of patients treated with this technique indicates that recovery is sustained, and relapse/wastage rate is low. There is need for further research in this significant aspect of military medicine.

ATTITUDINAL PROFILE OF MILITARY NURSING SERVICE OFFICERS.

A questionnaire designed to assess attitudinal profile was mailed to nursing officers in five representative military hospitals. 158 (77.83%) of 203 addressees responded. Cluster analysis indicated higher level of commitment in nursing officers with over 16 years service as compared to those with less than 5 years. Self-image and job-satisfaction, however tended to be eroded with increasing length of service which was also associated with a more authoritarian attitude, relatively less materialistic outlook and (paradoxically) greater negative attitude towards authority figures. Marriage and having children did not influence any parameter. The feeling of sexual harassment increased with seniority in service, as also a perceived erosion in the authority of the principal matron. Relatively junior nursing officers appeared dissatisfied with "too much paper work" and a felt deterioration in working environment as well as the image of Military Nursing Service.

POST-TRAUMATIC STRESS DISORDER IN POLY-TRAUMA CASES.

Six hundred and one patients, who sustained injuries in militant activities, admitted during a 7 month period to a zonal referral hospital were studied. The majority, 54.6% from the Armed Forces and 38.8% from the para-military forces, were in the age group of 22-53 years. There were 40 (6.7%) civilian casualties. These were in the age group of 20-45 years. A large number (75.7%) of the casualties manifested with post-traumatic stress symptoms. 24.3% of them were rated as post-traumatic stress disorder. Six months follow-up revealed persistence of post-traumatic stress disorder in 17.1% of the cases. By one year, 42.1% who responded to the follow-up letters had persistence of post-traumatic stress disorder in 4.95%. Early recognition of this psychic trauma and preventive strategies are discussed.

Overexpression of osmotin gene confers tolerance to salt and drought stresses in transgenic tomato (Solanum lycopersicum L.).

Abiotic stresses, especially salinity and drought, are major limiting factors for plant growth and crop productivity. In an attempt to develop salt and drought tolerant tomato, a DNA cassette containing tobacco osmotin gene driven by a cauliflower mosaic virus 35S promoter was transferred to tomato (Solanum lycopersicum) via Agrobacterium-mediated transformation. Putative T0 transgenic plants were screened by PCR analysis. The selected transformants were evaluated for salt and drought stress tolerance by physiological analysis at T1 and T2 generations. Integration of the osmotin gene in transgenic T1 plants was verified by Southern blot hybridization. Transgenic expression of the osmotin gene was verified by RT-PCR and northern blotting in T1 plants. T1 progenies from both transformed and untransformed plants were tested for salt and drought tolerance by subjecting them to different levels of NaCl stress and by withholding water supply, respectively. Results from different physiological tests demonstrated enhanced tolerance to salt and drought stresses in transgenic plants harboring the osmotin gene as compared to the wild-type plants. The transgenic lines showed significantly higher relative water content, chlorophyll content, proline content, and leaf expansion than the wild-type plants under stress conditions. The present investigation clearly shows that overexpression of osmotin gene enhances salt and drought stress tolerance in transgenic tomato plants.