Effect of vitamin E-enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene.

BACKGROUND: Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component's mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E-enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E-enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component. METHODS: Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated. RESULTS: The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05). CONCLUSIONS: A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E-enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care.

BACKGROUND: India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders' perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India. METHODS: We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar. RESULTS: The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process. CONCLUSION: Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Biodegradation of P-nitro phenol using a novel bacterium Achromobacter denitrifacians isolated from industrial effluent water.

In the present investigation, Achromobacter denitrifacians was isolated from industrial wastewater and used in the degradation of para nitro-phenol. Experiments were made as a function of different carbon sources, organic and inorganic nitrogen sources and metal ions to analyse the removal efficiency of para nitro-phenol present in the industrial wastewater sources. Observations revealed that the rate of phenol biodegradation was significantly affected by pH, temperature of incubation, glucose, peptone and metal ion concentration. The optimal conditions for phenol removal were found to be pH of 7.5, temperature, 35 °C and 0.25 gL-1 supplemented glucose level, 0.25 gL-1 supplemented peptone level, and 0.01 gL-1 zinc ion. The key importance of the present study is the utilization of a native bacterial strain isolated from the industrial effluent water itself having an impending role in the bioremediation process of phenol.

Efficacy of omega 3 fatty acid as an adjunct in the management of chronic periodontitis: A randomized controlled trial.

BACKGROUND: : Periodontitis is conventionally treated with both surgical and nonsurgical methods. Various adjuncts have been used previously with compromised efficacy. Recently omega-3(ώ-3) polyunsaturated fatty acids (PUFA) including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) were shown to have therapeutic anti-inflammatory and protective actions in inflammatory diseases including periodontitis. The purpose of the present study was to evaluate and compare the clinical efficacy of ώ-3 fatty acids as an adjunct to scaling and root planing in the treatment of periodontitis. METHODS: 110 Patients were selected for the study out of which 20 were excluded (12 not meeting the inclusion criteria and 8 refused to participate). 90 patients (48 in test and 42 in the control group) after randomisation through a coin toss method were enrolled in a single-blind randomised controlled trial conducted in the Periodontics department of a dental college. Full mouth subgingival scaling and root planing and ώ-3 fatty acid 500 mg (EPA/DHA 180/120 mg), BD daily for 1 month was given to the test group and subgingival scaling and root planing only was given to the control group. Clinical parameters like probing pocket depth, clinical attachment level, plaque index and gingival index were recorded at baseline, 1 and 3 months and were compared. RESULTS: Statistical analyses demonstrated a significant reduction in probing pocket depth (t = 65.56, P = 0.000) and (t = 51.69, P = 0.000) at 1 and 3 months, respectively, in test group compared to baseline and control group. There was a significant gain in clinical attachment level (t = 63.29, P = 0.000) and (t = 31.03, P = 0.000) at 1 and 3 months, respectively, in test group compared to baseline and control group. The gingival index shows an appreciable reduction in both groups, and in test group, it is statistically significant at 3 months (t = 2.15, P = 0.03). There was no statistical significant reduction in plaque index at 3 months (t = 0, P = 0.997). CONCLUSION: The present study showed that adjunctive use of ώ-3 fatty acids proved to be beneficial over scaling and root planing alone in the treatment of chronic moderate periodontitis. The beneficial effects were in terms of significant improvements in clinical parameters, probing pocket depth, and clinical attachment level and gingival index. Dietary modulation is now emerging as an adjunct to periodontal therapy. Hence, omega-3 fatty acid may be used routinely in the management of chronic periodontitis.

Radiologists Are Actually Well Positioned to Innovate in Patient Experience.

Patient experience is becoming increasingly prioritized, most notably as a component of recently passed health care legislation that aims to link physician reimbursement to quality of care and cost-effectiveness. For several reasons, radiologists are better positioned to seize opportunities to enhance patient experience than is readily apparent. We propose that discrete components along the imaging value chain can be evaluated specifically for their effect on patient experience and improved to this end. We also emphasize that the field of radiology has traditionally been the earliest adopter and a serial innovator in health information technology, and we suggest possible ways to leverage the newest technological tools to improve patient experience. Finally, we discuss how carefully vetted opportunities for direct patient interaction might expand the reach of diagnostic radiologists as members of integrated health systems. We believe that emerging patient experience metrics present unconventional opportunities for radiologists to make imaging even more meaningful for the many patients who entrust us with their care. SIX SUMMARY POINTS.

Improving Access to Image-guided Procedures at an Integrated Rural Critical Access Hospital: Ultrasound-guided Thyroid Biopsy Program.

PURPOSE: Critical access hospitals face difficulty providing all services locally and may need to refer patients off-site for additional care. Providing on-site minimally invasive biopsies, may obviate visits to tertiary or quaternary care centers. This study aims to assess feasibility and outcomes of an ultrasound-guided thyroid biopsy program in a critical access hospital. METHODS: In this HIPAA compliant, IRB approved study, the Interventional Radiology (IR) database of a 19-bed, island, rural, critical access hospital without onsite pathology services affiliated with our quaternary care institution was retrospectively reviewed to identify all thyroid biopsies that were performed on site since inception of the service in April 2014 through August 2016. A specialized biopsy and specimen collection protocol was created as each specimen was transferred to and analyzed by the pathology department at our affiliated quaternary care institution. RESULTS: Two IR physicians carried out thyroid biopsies on 34 nodules in 29 patients during the study period. The mean age of patients was 56.5 ± 14.0, with a range of 35-85 and 86% female, 14% male. 94.1% of nodules had adequate material for interpretation on the first biopsy and 97.1% upon repeat biopsy. Ultimately, 5 patients (with 6 nodules) underwent surgical resection at the integrated quaternary care center. Surgical resection identified one atypical follicular adenoma, one follicular variant of papillary thyroid carcinoma, two papillary carcinomas, and two Hürthle cell tumors. CONCLUSION: IR thyroid biopsy services may be successfully provided in the rural setting without onsite pathology analysis and adequacy checks, enhancing patient access and streamlining care while also expanding the reach of tertiary care centers.

Acupuncture - An effective tool in the management of gag reflex.

Gagging is of great concern to the dentist as it is a serious impediment during the execution of various dental procedures. The etiology of gagging is multifactorial, and several suggestions have been offered to arrest this reflex, some of which are nonsustainable and does not show the immediate result. Acupuncture has been successfully employed as an adjunct to local anesthesia in dental extractions, pain management and also in the symptomatic management of temporomandibular joint disorders. The author highlights the application of acupuncture in the management of patients with gag reflex during dental procedures and its benefits are reported.

Biochemical profiling and chemopreventive activity of phloretin on 7,12-Dimethylbenz (a) anthracene induced oral carcinogenesis in male golden Syrian hamsters.

OBJECTIVES: The present study was designed to examine the chemopreventive effects of phloretin against 7, 12-dimethylbenz (a) anthracene (DMBA) induced buccal pouch carcinogenesis in male golden Syrian hamsters in order to discover resources to improve the traditional medicine. MATERIALS AND METHODS: Hamsters were divided into four groups of 10 animals each. Group I was served as an untreated control. Group II hamsters were painted with 0.5% DMBA in liquid paraffin on the left buccal pouches three times a week for 14 weeks. Group III hamsters were orally administrated with phloretin at a dose of 40 mg/kg body Weight (b.wt) on days alternate to DMBA application. Group IV hamsters were orally administrated with phloretin alone and served as the drug control. The experiment was terminated at the end of fourteenth week. The experimental animal's tumors were subjected into morphological examination and subsequently screened the pathological changes and estimate the activities of bi-products of lipid peroxidation, antioxidants enzymes and phase I and II detoxification enzyme status. RESULTS: In DMBA alone treated hamster showed increased levels of lipid peroxidation by products, leads to decreased levels of enzymatic and non-enzymatic antioxidants status, activities of phase I and II detoxification enzyme status were altered. Normalized the neoplastic changes, decreased the levels of lipid by products, retain the antioxidants and restored the phase I and II enzymes were observed in phloretin administrated animals during DMBA induced oral carcinogenesis. CONCLUSION: Phloretin has possible chemopreventive role in which modulating the antioxidant and detoxification enzyme status, thereby retarding DMBA induced buccal pouch carcinogenesis.

Effect of acharya technique upon back pain among industrial workers.

Back pain is a universal problem affecting people from all regions of the world. Since relief using modern systems of medicine is hardly forthcoming, the efficacy of indigenously developed Acharya Technique was assessed. Using purposive sampling, data was collected from 30 industrial workers from Erode (TN). It was found that while 36.7 percent participants had complete discomfort in back pain before resorting to Acharya Technique, after its administration, 40percent had only mild discomfort in back pain, thus showing the effectiveness of this technique. It is suggested to include Acharya Technique in continuing educational programmes on wider scale.

Evaluation of the mutagenic potential and acute oral toxicity of standardized extract of Ocimum sanctum (OciBest™).

Ocimum sanctum L. (Lamiaceae) is found throughout India and in many parts of world. O. sanctum is used for the treatment of various health indications. In this lieu, it is of prime importance to investigate the safety aspects of the plant. Hence, the present study was conducted to investigate the possible genotoxic potential and acute oral toxicity of the extract of O. sanctum (OciBest™). The standard battery of in vitro genotoxicity tests, namely bacterial reverse mutation, chromosome aberration and micronucleus (MN) tests were employed to assess the possible mutagenic activity. The results showed that OciBest™ (7.9-2500.0 µg/mL) did not increase the number of histidine revertant colonies in Salmonella typhimurium strains (TA98 and TAMix) with and without exogenous metabolic activation (S9). OciBest™ (10.0-100.0 µg/mL) did not show structural chromosomal aberrations or increase in MN induction, with and without S9, at the tested dose range in both 4-h and 18-h exposure cell cultures. Thus, OciBest™ is not genotoxic in bacterial reverse mutation, chromosomal aberration and MN tests. In an acute oral toxicity test, rats were treated with 5 g/kg of OciBest™ and observed for signs of toxicity for 14 days and the results did not show any treatment-related toxic effects to Wistar rats.

Hypercalcemia associated with a malignant brenner tumor arising from a mature cystic teratoma.

A 60-year-old woman presented with abdominal pain and weight loss and was found to have serum calcium of 15.0 mg/dl. Serum parathyroid hormone-related peptide (PTHrP) returned elevated. Imaging suggested bilateral mature cystic teratomas. Her hypercalcemia was treated initially with intravenous saline, as well as intramuscular and subcutaneous calcitonin. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, and final pathology revealed malignant Brenner tumor in association with a mature cystic teratoma. Her postoperative PTHrP returned less than assay, and her total and ionized calcium fell below normal, requiring supplemental calcium and vitamin D. At follow-up one month after discharge, her calcium had normalized. We present the first reported case of hypercalcemia occurring in association with a malignant Brenner tumor. Malignancy-associated hypercalcemia occurs via four principal mechanisms: (1) tumor production of PTHrP; (2) osteolytic bone involvement by primary tumor or metastasis; (3) ectopic activation of vitamin D to 1,25-(OH)(2) vitamin D, and (4) ectopic production of parathyroid hormone. PTHrP-mediated hypercalcemia is the most common mechanism and was responsible in this case. In patients with paraneoplastic hypercalcemia who undergo surgical treatment, close monitoring and management of serum calcium is necessary both pre- and postoperatively.

Biosynthesis of silver nanoparticles by using mangrove plant extract and their potential mosquito larvicidal property.

OBJECTIVE: To identify the larvicidal activities of silver nano particles synthesised with Rhizophora mucronata (R. mucronata) leaf extract against the larvae of Aedes aegypti (Ae. aegypti) and Culex quinquefasciatus (Cx. quinquefasciatus). METHODS: In vitro larvicidal activities such as LC(50) and LC(90) were assessed for the Ae. aegypti and Cx. quinquefasciatus larval species. Further, characterisation such as UV, XRD, FTIR and AFM analysis were carried out for the synthesised silver nano particles. RESULTS: The LC(50) value of the synthesised silver nano particle was identified as 0.585 and 0.891 mg/L for Ae. aegypti and Cx. quinquefasciatus larvae respectively. Further, the LC(90) values are also identified as 2.615 and 6.291 mg/L for Ae. aegypti and Cx. quinquefasciatus species respectively. The synthesised silver nanoparticles have maximum absorption at 420 nm with the average size of 60-95 nm. The XRD data showed 2θ intense values with various degrees such as 37.10°, 47.66°, 63.97° and 70.01°. The FTIR data showed prominent peaks in (3 426.89, 2 925.49, 2 869.56, 2 346.95, 1 631.49, 1 031.73, 669.18 and 455.12) different ranges. CONCLUSIONS: The biosynthesis of silver nanoparticles with leaf aqueous extract of R. mucronata provides potential source for the larvicidal activity against mosquito borne diseases.

In vitro safety evaluation and anticlastogenic effect of BacoMind on human lymphocytes.

OBJECTIVE: BacoMind (BM) is a standardized extract of Bacopa monnieri, which belongs to the family Scrophulariaceae and is a creeping annual plant found throughout the Indian subcontinent. It has been used by Ayurvedic medicinal practitioners in India for almost 3000 years and is classified as a medharasayana, a substance which improves memory and intellect. With the widespread traditional use as well as scientific validation of Bacopa monnieri for nootropic activity, a bioactive-rich unique phytochemical composition-BacoMind was developed from B. monnieri for use as a cognition and memory enhancing agent. The present study aimed to investigate the in vitro toxicity of this formulation of BacoMind on human lymphocytes and to rule out its possible contribution to mutagenicity. METHODS: In the present investigation the active ingredients present in BM were identified and quantified by high performance liquid chromatography (HPLC) and high performance thin-layer chromatography (HPTLC). Antioxidant and anticlastogenic properties of BM were studied in vitro with and without metabolic activation. Doses of BM were chosen on the basis of mitotic index (MI) and cytokinesis-block proliferation index (CBPI). Clastogenicity assays were performed at 31.2 microg/mL, 62.5 microg/mL, and 125 microg/mL, while the Salmonella reverse mutation assay (Ames test) was performed at doses of 61.72, 185.18, 555.55, 1666.67, and 5000.00 microg/plate. RESULTS: HPLC and HPTLC analysis of BM revealed the presence of bacoside A3, bacopaside I, bacopaside II, jujubogenin isomer of bacopasaponin C, bacosine, luteolin, apigenin, bacosine, and beta-sitosterol D glucoside. BM demonstrated significant antioxidant activity. The number of chromosomal aberrations and the frequency of micronuclei induced by BM were not statistically significant up to a dose of 62.5 microg/mL. A subsequent dose of 125 microg/mL prior to metabolic activation induced mild clastogenicity, but it was found to be biologically insignificant as this effect was not seen post metabolic activation. BM also demonstrated a dose-dependent protection against the clastogens used in this study using the above tests for clastogenicity. Maximum protection was observed in presence of metabolic activation. Moreover, BM demonstrated no mutagenic effect on the tested strains, as observed in the Ames test. CONCLUSION: BM protected human lymphocytes against various clastogens. BM also exhibited high antioxidant activity which might be responsible for the observed protective effects against the clastogens since the used clastogens are known to induce their clastogenic effects via production of oxidative radicals.

Revision peripheral nerve surgery.

The treatment of chronic neuropathic pain with revision surgical procedures can be beneficial. A thorough evaluation can help to guide treatment to optimize outcome. With an increasing understanding of the pain-generating mechanisms and the appropriate application of surgical interventions, quality of life and function continues to be improved in patients who have otherwise significant disability.

Non-pharmacological management of essential hypertension.

Lifestyle modifications are universally accepted, not only as the first step in the management of hypertension but also a way to prevent hypertension. The INTERSALT study of 52 communities worldwide showed that weight, among all measured characteristics except age, had the strongest, significant, most consistent and independent correlation with blood pressure. INTERSALT epidemiological data had demonstrated a positive association between sodium intake and level of blood pressure. A rigorous analysis of 23 randomly controlled trials showed that 100 mmol/day reduction in sodium intake was associated with a decline of 5-7 mm Hg (systolic)/2.7 mm Hg (diastolic) in hypertensive subjects. Excessive alcohol consumption is another important risk factor for hypertension and has been reported to account for 5-30% of all hypertension. Moderately intense exercise at 40 to 60% of maximum oxygen consumption e.g., 30 to 45 minutes of brisk walking on 4-5 days a week, can lower blood pressure. The incidence of stroke and coronary artery disease in hypertensive patients who smoke is 2-3 times greater than in non-smoking patients with comparable blood pressure and stopping smoking rapidly reduces this risk. There have been several studies showing the stress reduction with various behavioural procedures, such as yoga, relaxation biofeedback, transcedental mediation and psychotherapy benefit hypertensive patients by lowering their blood pressure.