A new anti-inflammatory lupane in Ziziphus jujuba (L.) Gaertn. var. hysudrica Edgew.

Objectives: To investigate extracts of the stem bark of Ziziphus jujuba (L.) Gaertn. var. hysudrica Edgew. (Rhamnaceae) for anti-inflammatory activity and isolate the active principle(s). Methods: The dry powder was macerated separately in three types of solvents to prepare methanol extract (ME), ethyl acetate extract (EE), and chloroform extract (CE). Following in vitro anti-inflammatory screening, the most active extract was selected to isolate the active compound. Both, the active extract and isolated compound were further tested on rats using the carrageenan-induced inflammation model. The blood and paw tissue were subjected to qPCR, and histopathology, respectively. Key findings: CE showed comparatively higher anti-inflammatory activity (85.0-95.0 %) in all in vitro assays, except the heat-induced membrane stabilization model (p < 0.05), and upon column chromatography, it yielded a pure crystalline compound. The compound was a pentacyclic triterpenoid (Lupane), named as hydroxymethyl (3ß)-3-methyl-lup-20(29)-en-28-oate (Hussainate). CE (500 mg/kg) and Hussainate (1.0 mg/kg) reduced edema in 5 h after carrageenan administration. The activity of Hussainate was found to be comparable to that of dexamethasone (standard). The possible activity mechanism was the downregulation of tumor necrosis factor-alpha (TNF-α), cyclooxygenase-2 (COX-II), NF-κB, and IL-1ß. Conclusions: This study reveals that chloroform extract of the stem's bark of Z. jujuba may be used to prepare standardized anti-inflammatory herbal products using Hussainate as an active analytical marker. Hussainate may be used as a lead to develop anti-inflammatory drugs.

Horner syndrome-A rare complication after thyroidectomy for benign thyroid swelling.

Horner syndrome occurring after thyroidectomy is a rare entity and most of the reported cases have happened after surgeries on malignant thyroid swellings. In the present report, we describe a 27-year-old female who developed ptosis, miosis, enophthalmos, and anhidrosis on the second post-operative day after thyroidectomy for benign goiter. Post-operative ultrasound, computed tomography of neck, nerve conduction study, and electromyography of brachial plexus were unremarkable. Patient was kept on conservative management. She was given short course of Prednisolone orally for 2 weeks and was discharged on 150 mcg thyroxine. She had significant improvement in ptosis, miosis, and enophthalmos after six months. Horner syndrome is a rare but an important complication after thyroidectomy which may lead to cosmetic disfigurement. Surgeons should be well aware of this possibility and its presentation for timely recognition and management postoperatively. Early intervention should be done for any reversible cause, i.e., hematoma and oral steroids should be initiated as early as possible.

Chylous ascites: Why exercise is bad for you.

INTRODUCTION: The development of chylous ascites is usually associated with trauma, iatrogenic or otherwise. Blunt abdominal trauma producing hyperextension or hyperflexion may cause disruption to lymphatic vessels causing chylous ascites. PRESENTATION OF CASE: This report describes the case of a 38-year-old gentleman who presented to the emergency department with severe abdominal pain after completing a triathlon. As the patient was in severe pain, an abdominal CT was performed which demonstrated a possible mid gut volvulus. Subsequent laparotomy noted a significant volume of intra-abdominal chyle with no other abnormalities. DISCUSSION: This is the first report of chylous ascites occurring without associated abdominal pathology after a period of strenuous exercise. CONCLUSION: Chylous ascites can occur as a result of hyperreflexion and hyperextension injuries sustained during strenuous exercise.

Risk of cardiovascular events in patients with polycystic ovary syndrome.

Women with polycystic ovary syndrome (PCOS) have increased prevalence of cardiovascular (CV) risk factors. However, data on the incidence of CV events are lacking in this population. Using Rochester Epidemiology Project resources, we conducted a retrospective cohort study comparing CV events in women with PCOS with those of women without PCOS in Olmsted County, Minnesota. Between 1966 and 1988, 309 women with PCOS and 343 without PCOS were identified. Mean (SD) age at PCOS diagnosis was 25.0 (5.3) years; mean age at last follow-up was 46.7 years. Mean (SD) follow-up was 23.7 (13.7) years. Women with PCOS had a higher body mass index (29.4 kg÷m2 vs 28.3 kg÷m2; p=.01). Prevalence of type 2 diabetes mellitus and hypertension and levels of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides were similar in the two groups. We observed no increase in CV events, including myocardial infarction (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.32 to 1.72; p=.48); coronary artery bypass graft surgery (adjusted HR 1.52; 95% CI 0.42 to 5.48; p=.52); death (adjusted HR 1.03; 95% CI, 0.29 to 3.71; p=.96); death due to CV disease (adjusted HR 5.67; 95% CI 0.51 to 63.7; p=.16); or stroke (adjusted HR 1.05; 95% CI 0.28 to 3.92; p=.94). Although women with PCOS weighed more than controls, there was no increased prevalence of other CV risk factors. Furthermore, we found no increase in CV events. While prospective studies are needed to confirm these findings, women with PCOS do not appear to have adverse CV outcomes in midlife.

Vascular invasion is not a risk factor in oesophageal cancer recurrence.

AIM: The outcome of the treatment of oesophageal cancer remains poor despite improved treatment modalities and recurrence remains a major problem despite improved staging and treatment. The aim was to identify the independent risk factors responsible in the recurrence of oesophageal cancer. METHODS: The patients who had elective oesophagectomy (n = 244) with curative intent were studied. One hundred and eighty four patients had surgery alone, 44 patients had neo-adjuvant chemotherapy and surgery while 16 patients had neo-adjuvant chemotherapy, surgery and adjuvant chemotherapy. We have analyzed patients who had surgery alone (n = 184). Data was collected for demography, type of operation, histology, staging (TNM), vascular invasion (VI), differentiation of tumour, type of chemotherapy and recurrence of tumour. RESULTS: The median age was 67 years (IQR 60, 71). The T1, T2, T3 distribution was 10%, 24% and 66% respectively. Forty percent had no nodal involvement (N0) and 60% had N1 stage disease. Twenty three percent of patients had vascular invasion. Univariate analysis of histo-pathological factors identified lymph node yield (p = 0.06), curative resection R0 (p = 0.004) and vascular invasion (VI) (P = 0.69) as prognostic indicators of recurrence. Multivariate analysis showed that number of lymph nodes yielded (p = 0.01) and R0 resection remain independent indicators of recurrence of tumour. However, VI (p = 0.2) and age at disease onset (p = 0.8) were not indicators of recurrence in oesophageal cancer patients. CONCLUSION: R0 and lymph node yield may help to predict the recurrence of oesophageal cancer. However the presence of VI may not be a significant risk factor in disease recurrence.

Role of routine oesophago-gastroduodenoscopy before cholecystectomy.

INTRODUCTION: A proportion of patients do not get symptomatic relief after cholecystectomy because there is an overlap in the symptomology of biliary and gasroduodenal pathologies. In our unit all the patients are offered gastroscopy prior to Cholecystectomy. Aim of this study was to evaluate the efficacy of gastroscopy in all patients with upper abdominal pain irrespective of ultrasound findings. MATERIAL AND METHODS: This retrospective study was carried out, between Jan 2001-Oct 2003. All the patients undergoing laparoscopic cholecystectomy by a single surgeon were studied. Group 1 (n = 61) were not endoscoped before the operation (Jan 2001-May 2002). Group 2 (n = 60) had routine endoscopy carried out before surgery (June 2002-October 2003). The results were entered in a database and analyzed. RESULTS: Total of 240 laparoscopic cholecystectomies were carried out. Female to male ratio was 4:1. In Group 1, the recurrence or persistence of symptoms was 20/61 (32.78%) patients who were not scoped. In Group 2, all patients were scoped with positive findings in 35% of the patients. All were treated for the pathology and only 2(3.3%) had recurrence or persistence of symptoms. CONCLUSION: The routine use of gastroscopy before laparoscopic cholecystectomy helps to reduce persistence of symptoms and is recommended.

A review article on gastric volvulus: a challenge to diagnosis and management.

Acute gastric volvulus is a life-threatening condition, but its intermittent nature and vague symptoms may make diagnosis difficult. Imaging is usually only diagnostic if carried out when patients are symptomatic. The population affected ranges from paediatric age group to elderly with multiple co-morbidities. Laparoscopic repair is advisable once a diagnosis is reached. This review on gastric volvulus focuses on the diagnostic and management challenges encountered, together with strategies for dealing with them. Lessons have emerged which may assist in dealing with such a rare presentation in future.

Androgen receptors may act in a paracrine manner to regulate oesophageal adenocarcinoma growth.

BACKGROUND: The role of androgen receptors (ARs) in tumorigenesis, including transcription of fibroblast growth factors (FGFs), is established in prostate cancer. This study examined the role of ARs and FGFs in oesophageal adenocarcinoma (EAC), where tumour incidence in males is higher. METHODS: AR gene expression was analysed using quantitative RT-PCR; AR, fibroblast growth factor receptor-1 (FGFR-1) and fibroblast growth factor-8 isoform b (FGF-8b) protein by immunohistochemistry; and serum steroid levels (testosterone, progesterone, luteinising hormone and follicle stimulating hormone (FSH)) by immunoassay. A human oesophageal adenocarcinoma cell line was grown subcutaneously in nude mice. RESULTS: AR gene expression was of significantly higher levels than oesophageal adenocarcinomas (n=21, p=0.002) and in the squamous carcinoma line (OE21) compared with the adenocarcinoma lines (OE33 and OE19). Median serum testosterone levels in oesophageal carcinoma patients were higher than in age-matched controls (p=0.01) and reduced postoperatively, in patients undergoing curative resection (p=0.006). No significant differences were observed in hormones except FSH, where preoperative levels were significantly higher in the EAC group. AR protein was expressed in normal oesophageal squamous epithelial cells and also in the stroma of 18/23 EAC samples. FGFR-1 protein was expressed in malignant epithelium of 23/23 tumour samples. OE19 xenografts grew faster in male versus female mice (tumour weight at day 21, 1.14 g and 0.28 g, respectively, p=0.005) and had elevated FGF receptor expression. CONCLUSIONS: AR expressed in the stroma of oesophageal adenocarcinomas may induce paracrine effects following stimulation by androgens (including tumour-derived), possibly via FGFs, including FGF-8b.

Ovarian cancer presenting as chest wall subcutaneous nodule: a case report and a literature review.

BACKGROUND: Distant metastasis from primary epithelial ovarian carcinoma is commonly found as nodal and intraperitoneal spread, spread via haematogenous routes or transcoelomic spread. Ovarian cancer presents in different ways, but common presentations include abdominal pain, distention or ascites due to metastatic involvement of peritoneal cavity. Most tumour present at advanced stage and distant metastases to common and uncommon sites are found in patients who have undergone treatment for primary ovarian cancer. Subcutaneous metastatic nodules from primary ovarian cancer are rarely found in advanced disease. We describe a case of asymptomatic ovarian carcinoma presenting as a chest wall nodule. CASE: An unusual case of primary ovarian carcinoma presenting as asymptomatic chest wall subcutaneous nodules that subsequently were diagnosed as metastatic lesions. CONCLUSION: An unusual case of ovarian carcinoma where the patient was totally asymptomatic and referred with two tiny subcutaneous nodules. Therefore, lumps of recent onset, although asymptomatic, should either have fine needle aspiration cytology or excision biopsy.

A phase II study of G17DT in gastric carcinoma.

PURPOSE: G17DT is a gastrin immunogen, raising antibodies that blockade gastrin-stimulated growth. The aim of the study was to characterise antibody response and assess safety and tolerability of G17DT given to patients with gastric cancer. EXPERIMENTAL DESIGN: G17DT was administered to 52 patients with gastric adenocarcinoma at weeks 0, 2 and 6 by intramuscular injection at doses of 10, 100 and 250 microg. Antibody levels were measured by an ELISA assay. A radioligand displacement assay determined the ability of G17DT-immunised patients' sera to inhibit binding of 125IG17 to cholecystokinin (CCK)-2 receptors. RESULTS: By week 12 of the study, 6/12 evaluable stage I-III patients achieved an antibody response in the 10 microg group, 7/11 in the 100 microg group, and 11/12 in the 250 microg group. Stage IV patients dosed at 250 microg achieved a similar response rate to stage I-III patients dosed at 10 or 100 microg. G17DT was well tolerated in 47/52 patients. Two patients suffered significant adverse reactions including injection site pain and abscess. G17DT antibodies displaced iodinated gastrin from CCK-2 receptors, with the level of displacement correlating with antibody titre. CONCLUSIONS: G17DT immunisation is a well-tolerated method of raising functional antibodies to 17 amino acid gastrin forms in patients with gastric carcinomas.

Expression of a novel protein by regenerating hepatocytes and peripheral blood lymphocytes.

Regeneration and tolerance factor (RTF) is a protein with immunosuppressive activity and is normally present in the thymus and placenta. RTF was measured in the livers of patients with regenerating nodules due to alcoholic cirrhosis and hepatitis C. RTF was expressed in the regenerating nodules of 26 patients with alcoholic cirrhosis. All patients with chronic hepatitis C without cirrhosis failed to express RTF. Flow cytometry revealed upregulation of RTF on the lymphocytes from alcoholic cirrhosis and downregulation in hepatitis C disease.

Periampullary diverticula and pancreaticobiliary disease.

BACKGROUND: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients. METHODS: The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed. RESULTS: The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres. CONCLUSION: With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

An audit of emergency abdominal aortic aneurysm repair to establish the necessity for an emergency vascular surgical rota.

Mortality for emergency abdominal aortic aneurysm (AAA) repair remains high but results of specialist vascular surgeons are superior to those of general surgeons. A retrospective audit was performed on all patients undergoing emergency AAA repair over 53 months at one hospital to determine the necessity for a vascular specialist on-call rota. Patients were stratified into two groups, those treated by specialist vascular surgeons and those treated by general surgeons. There were 37 patients in the vascular surgeon group and 36 in the general surgeon group. There was no significant difference between the two groups when age, sex distribution, APACHE II score on admission, pre-operative delay and type of rupture were considered. The average operating time was 114.7 min in the vascular surgeon group and 111.9 min in the general surgeon group. Total blood transfusion requirements, and postoperative duration of ventilation, inotrope therapy and intensive treatment unit stay were similar in the two groups. Intra-operative, 30-day and cumulative hospital mortalities were 10.8% versus 8.3%, 32.4% versus 38.9% and 40.5% versus 38.9% in the vascular surgeon and general surgeon groups, respectively. The mortality figures compare favourably with other published series. As the results of the two groups were similar, there is currently no need for vascular surgeons to be routinely available for acute AAA surgery at our hospital.

Tension pneumothorax complicating diagnostic upper endoscopy: a case report.

Hypoxemia is common during various endoscopic procedures and may result from a variety of causes. These causes range from benign and otherwise easily reversible events like oversedation to potentially life threatening complications such as pneumothorax. Although pneumothorax has been reported secondary to gastrointestinal perforation as a complication of various therapeutic endoscopic procedures, there has been no report of pneumothorax without perforation. We report a case of a patient who developed severe hypoxemia and hemodynamic instability during diagnostic upper endoscopy as a result of pneumomediastinum and tension pneumothorax in the absence of any signs of gastrointestinal perforation and comment on various possible mechanisms. Immediate endotracheal intubation and bilateral chest tube placement resulted in prompt return of the patient's oxygenation and vital signs back to normal. This report enlarges the list of possible causes of hypoxemia during endoscopy and shows the importance of early and prompt recognition, which allowed directed therapy with a good outcome.

Periampullary diverticula: consequences of failed ERCP.

Periampullary diverticula (PAD) are associated with biliary disease and contribute to failure of endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. The presence of PAD and causes of failure to cannulate the ampulla were noted in 1211 consecutive patients undergoing ERCP. Case notes of 100 consecutive patients with PAD were reviewed retrospectively. Overall prevalence of PAD was 9%. Prevalence was higher in patients > or = 75 years when compared with those < 75 years (19.2% vs 4.8%, P < 0.0001). Ampullary cannulation was successful in 62.4% of patients with PAD and 92.7% without PAD (P < 0.0001). Success rates were lower in patients with intradiverticular papillae than in those with juxtapapillary diverticula (38.1% vs 77.6%; P < 0.0001). Of 19 patients with PAD who did not have any imaging other than ultrasound, 16 were asymptomatic over a median follow-up of 20 months. Biliary surgery was performed on 35 patients, with no major complication. PAD are a major cause of failed ERCP. Failure rates are higher in patients with intradiverticular papillae than juxtapapillary diverticula. Though a large proportion of patients not imaged remain asymptomatic on follow-up, it is difficult to predict which patients may form this group. Surgery, when indicated, is safe and effective in elderly patients in whom ERCP has failed.

Gastroparesis after celiac plexus block.

A 36-yr-old woman with metastatic mucinous cystadenocarcinoma of the pancreas underwent neurolytic celiac plexus block with 100% ethanol and 0.5% bupivacaine for intractable back pain. Several hours after the procedure she developed severe nausea and vomiting, which persisted for days despite cessation of opioid analgesics, and administration of intravenous metoclopramide and ondansetron. Both esophagogastroduodenoscopy and barium examination of the stomach and small intestine showed excess gastric fluid but no evidence of mechanical obstruction. A radionuclide study revealed delayed gastric emptying of solids. Treatment with oral cisapride 10 mg p.o. q.i.d. resulted in considerable symptomatic improvement. We document the first reported case of gastroparesis after celiac plexus block and discuss possible etiological mechanisms.

Psoas abscesses complicating colonic disease: imaging and therapy.

Most surgeons think of psoas abscesses as a very rare condition related to tuberculosis of the spine, but in contemporary surgical practice they are more usually a complication of gastrointestinal disease. A case note study was undertaken on all patients treated for psoas abscess at two large hospitals in the mid-Trent region over a 2-year period. All seven patients presented with pyrexia, psoas spasm, a tender mass and leucocytosis. The diagnosis was made on abdominal radiographs in one patient, CT scan in three, MRI in two, and ultrasound in one. Aetiological factors included Crohn's disease in three, appendicitis in two, and sigmoid diverticulitis and metastatic colorectal carcinoma in one each. Six patients underwent transabdominal resection of the diseased bowel, retroperitoneal debridement and external drainage of the abscess cavity. Percutaneous drainage was performed in one. Two patients had more than one surgical exploration for complications. There were no deaths and the hospital stay ranged from 8-152 days. Psoas abscess can be a difficult and protracted problem. Bowel resection, thorough debridement, external drainage and concomitant antibiotics are essential for psoas abscesses complicating gastrointestinal disease. Defunctioning stomas may be necessary. However, in some cases a multidisciplinary approach may be required, as psoas abscesses can involve bone and joints.