Management of incidentally detected gallbladder carcinomas in a high prevalence area of gallbladder cancer.

BACKGROUND: There is an increasing incidence of advanced unresectable gallbladder cancer even in patients who undergo re-exploration and these cases are marked by poor survival even after undergoing curative resection and adjuvant chemotherapy. Lack of suspicion during primary surgery, unavailability of frozen section facilities and delayed referrals are believed to contribute to this high incidence. AIM: Our aim was to evaluate the results of re-surgery in incidental gallbladder cancers detected after open or laparoscopic cholecystectomy and to assess the outcome in patients who underwent complete radical cholecystectomy and adjuvant therapy. METHOD: We retrospectively analyzed the data from a prospectively maintained computerized database of all patients with incidentally detected gallbladder cancers operated in the Department of Surgical Oncology, from June 2006 to January 2013. RESULTS: Forty-two patients with incidental gallbladder cancer were re-explored. The median time of re-exploration after initial surgery was 65 days. Eighteen (43%) patients were found inoperable due to locally advanced unresectable or metastatic disease. Among the 24 (57%) patients who underwent completion radical cholecystectomy, 11 developed recurrence over a median time of 11 months. CONCLUSION: Despite the dismal prognosis, more than half of the incidentally detected gallbladder carcinoma patients could receive curative treatment. Identification of patients with incidentally discovered gallbladder cancer and early referral to an oncology center may ensure these patients receive curative resection thereby increasing their chances for long-term disease free survival.

Solar-driven seawater desalination via plasmonic hybrid MOF/polymer and its antibacterial activity.

In recent years, solar seawater desalination has been considered to be a promising and cost-effective technique to produce clean sources for water treatment and water deficiency. In addition, this technique shows high photothermal conversion efficiency by solar collectors to transfer solar energy into heat and the transformation of molecules in the capillaries of solar evaporators. In this study, we report the preparation of graphene-supported MIL-125 with polyurethane foam (MGPU) for solar steam generation. We modified MGPU by using the plasmonic nanoparticles of Ag and a polymer of polyaniline to increase the evaporation rate. Polyurethane foam can float on the surface of water and self-pump water by its hydrophilic porous structure, superior thermal insulation capabilities, and easy fabrication. MIL-125 has a high salt rejection and higher water permeability. It can reduce the affinity between water molecules and the pore surface of membrane, making it simple for water molecules to move through the pores. GO is a great alternative for steam generation applications since it exhibits broad-band light. The strong solar absorption, photothermal conversion efficiency, and photoreaction efficiency are enhanced by the use of silver nanoparticles in the photoreaction. The salt resistance capability is enhanced in saline water in the presence of polyaniline in a composite. Under one solar irradiation, the Ag/PANI/GO@MIL-125 (Ag-PMG) nanocomposite demonstrates an average 1.26 kg m2 h-1 rate of evaporation and an efficiency as high as 90%. The composite exhibits remarkable stability and durability after more than 10 cycles of use without a noticeable decrease in activity. In addition, the composite exhibits excellent organic dye removal from contaminated water and generates pure condensed freshwater. The antibacterial photoactivity of the photocatalysts was examined against B. subtilis and E. coli. The results demonstrate that Ag-PMG shows higher antibacterial activity than MIL-125 and PMG. It was shown that the presence of rGO, PANI, and Ag in the sample enhances the antimicrobial activity.

Herbal Approaches to Pediatric Functional Abdominal Pain.

Chronic abdominal pain is one of the most common problems seen by both pediatricians and pediatric gastroenterologists. Abdominal-pain-related functional gastrointestinal disorders (AP-FGIDs) are diagnosed in children with chronic and recurrent abdominal pain meeting clinical criteria set forth in the Rome IV criteria. AP-FGIDs affect approximately 20% of children worldwide and include functional dyspepsia (FD), irritable bowel syndrome (IBS), functional abdominal pain (FAP), and abdominal migraine. IBS accounts for 45% of pediatric AP-FGIDs. The pathophysiology of functional abdominal pain involves an interplay of factors including early life events, genetics, psychosocial influences, and physiologic factors of visceral sensitivity, motility disturbance, altered mucosal immune function, and altered central nervous system processing. Treatment approaches are varied and can include dietary, pharmacologic, and complementary medicine interventions, as well as psychosocial support, depending on the many aspects of the disorder and the needs of the individual patient. There is a strong interest in complementary and integrative medicine approaches to pediatric pain from both patients, providers, and families. In this article, we discuss popular herbal treatments typically used in the field of complementary medicine to treat pediatric AP-FGIDs: peppermint oil, Iberogast®, cannabis, fennel, and licorice. While high-quality data are rather limited, studies generally show that these remedies are at least as effective as placebo, and are well tolerated with minimal side effects. We will need more placebo-controlled, double-blind, and unbiased prospective studies to document and quantify efficacy.

Green construction of eco-friendly phosphotungstic acid Sr-MOF catalysts for crystal violet removal and synthesis of coumarin and xanthene compounds.

There is an urgent need to improve engineering and synthetic chemistry, either through the use of eco-friendly starting materials or the proper design of novel synthesis routes. This reduces the contamination of toxic chemicals and helps the disposal of organic dyes. In the current work, a metal-organic framework-based Sr(ii) was fabricated to achieve the desired goal for dye removal and catalysis. Sr-MOF-based phosphotungstic acid (PWA/Sr-MOF) was hydrothermally synthesized to study its adsorption and catalytic activities. Remarkably, about 99.9% of crystal violet (CV) dye was removed using PWA/Sr-MOF within 90 min at room temperature. Various factors have been studied to investigate the optimum conditions such as pH of solution, initial dye concentration, contact time, and temperature. The maximum adsorption capacity of CV dye was reached after 90 min and well fitted the pseudo-second kinetic order and Langmuir adsorption isotherm. Coumarin and xanthene reactions were chosen to test the catalytic activity of the prepared PWA/Sr-MOF at 373 K. Furthermore, structural and chemical characterization of the fabricated samples was obtained using FT-IR, XRD, TGA, DTA, TEM, EDX, and XPS. PWA/Sr-MOF can be considered as a promising and green framework in the material design used to study catalytic and adsorption performances.

A prospective, parallel group, open-labeled, comparative, multi-centric, active controlled study to evaluate the safety, tolerability and benefits of fixed dose combination of acarbose and metformin versus metformin alone in type 2 diabetes.

OBJECTIVE: The present study was a prospective, parallel group, open-labeled, comparative, multicentric, active controlled study to evaluate the safety, tolerability and benefits of fixed dose combination of acarbose and metformin versus metformin alone in type 2 diabetic patients. METHODS: A total of 229 patients with type 2 diabetes were enrolled at 5 medical centers across India. They received either acarbose (50 mg) + metformin (500 mg) bid/tid (n=115) or metformin monotherapy (500 mg) bid/ tid (n=114) for 12 weeks. Primary objective was to evaluate safety and tolerability based on the adverse events reported. Secondary objective was efficacy assessment based on changes in fasting, post prandial blood glucose and HbA1c values. RESULTS: In the acarbose + metformin group 10 patients reported 14 adverse events while in metformin group 9 patients reported 10 adverse events. No patient reported any serious adverse event or was withdraw from study because of adverse events. In the acarbose plus metformin group fasting blood glucose (FBG) decreased from a baseline of 158.85 +/- 18.14 mg/dl to 113.55 +/- 19.38 mg/dl (p < 0.0001) (decrease of 45.30 +/- 15.30 mg/dl) at 12 weeks, while in the metformin group fasting blood glucose decreased from a baseline of 158.31 +/- 26.53 mg/dl to 130.55 +/- 28.31 mg/dl (p < 0.0001) (decrease of 27.76 +/- 22.91 mg/dl) at 12 weeks. In the acarbose plus metformin group postprandial blood glucose (PPBG) decreased from a baseline of 264.65 +/- 34.03 mg/dl to 173.22 +/- 31.40 mg/dl (p < 0.0001) (decrease of 91.43 +/- 28.65 mg/dl) at 12 weeks, while in the metformin group PPBG decreased from a baseline of 253.56 +/- 36.28 mg/dl to 205.36 +/- 39.49 mg/dl (p < 0.0001) (decrease of 48.20 +/- 32.72 mg/dl) at 12 weeks. In the acarbose plus metformin group glycosylated haemoglobin (HbA1c) decreased from a baseline of 9.47 +/- 0.69% to 7.71 +/- 0.85% (p < 0.0001) (% decrease of 1.76 +/- 1.11) at 12 weeks, while in the metformin group HbAlc decreased from a baseline of 9.32 +/- 0.65% to 8.26 +/- 0.68% (p < 0.0001) (% decrease of 1.06 +/- 0.66) at 12 weeks. The combination of acarbose and metformin was found to be significantly superior in lowering the FBC (p < 0.0001), PPBG (p < 0.0001) and HbA1c (p < 0.0001) at 12 weeks as compared to metformin monotherapy. CONCLUSIONS: Fixed dose combination of acarbose and metformin was well tolerated and it was superior to metformin monotherapy in controlling FBG, PPBG and HbA(1C) levels in Type 2 Diabetes Mellitus patients.

Topographic electroencephalogram of propofol-induced conscious sedation.

OBJECTIVES: To determine the effects of increasing doses of propofol that induce conscious sedation on the topographic electroencephalogram (EEG) of human volunteers and to test the hypothesis that more frontal brain areas are affected by low doses of propofol. METHODS: The scalp EEG was recorded monopolarly from 16 different sites based on the 10-20 International System. Microcomputer-based hardware and RHYTHM 7.1 software were used to obtain quantitative power frequency topographic EEG data. A total of 10 normal adult volunteers were given incremental doses of propofol targeted to plasma concentrations of 0 to 1200 ng/ml. RESULTS: Sedative concentrations of propofol produced a dramatic increase in beta 1, an increase in alpha 2 and beta 2, and an increase in delta activity at the largest concentration, with almost no change in theta activity. The increase in beta 1 activity had a linear correlation with plasma propofol levels (r = 0.9). Topographic mapping indicated that beta 1 activation was primarily in the frontal and central regions, with focal changes more in the left hemisphere. CONCLUSIONS: Topographic brain EEG mapping techniques indicate that frontal brain beta 1 EEG activity may be useful as an objective brain index of propofol conscious sedation.

Synthesis and antitumour effect of the melanogenesis-based antimelanoma agent N-propionyl-4-S-cysteaminylphenol.

Chemotherapy of malignant melanoma is still a great challenge, as no effective drugs are available. The development of melanogenesis-based drugs is a promising area of research because melanogenesis is a unique biochemical pathway operating only in melanoma cells (and their normal counterparts) so that the tumour can be targeted. We have been using cysteinylphenol, a sulphur-containing analogue of tyrosine, and derivatives for that purpose. N-Acetyl-4-S-cysteaminylphenol was found to have the best antimelanoma effect in cell culture systems and in mice bearing B16 melanoma tumours. It also caused depigmentation of the skin, suggesting the possibility of use as a hypopigmenting agent. To improve the efficiency of the drug, we thought of replacing the acetyl group in N-acetyl-4-S-cysteaminylphenol with a propionyl group in the hope that increased hydrophobicity would increase the cellular uptake of the drug. N-Propionyl-4-S-cysteaminylphenol was synthesized by condensing 4-hydroxythiophenol with 2-ethyl-2-oxazoline. The drug showed both cytostatic and cytocidal effects in a human melanotic melanoma cell line. The drug was found to be a good depigmenting agent for the black hair follicles of C57 black mice when given s.c. for 14 days. A 10-day treatment with N-propionyl-4-S-cysteaminylphenol at 300 mg/kg body weight reduced the growth rate of B16 melanoma s.c. tumours in mice by 36%. The propionyl derivative was found to increase the life span of mice bearing melanoma more effectively than did the acetyl derivative.

The significance of anti-HAV in different population sectors in Lebanon: a comparative seroepidemiologic study.

A comparative seroepidemiologic survey was performed on the prevalence of antibody to HAV (anti-HAV) in 772 subjects in Lebanon. The results show that 97.7% of the adult Lebanese carry anti-HAV in their sera irrespective of geographic or socioeconomic factors, as compared to 38.8% of the adult foreign population. In the paediatric group, the highest prevalence of anti-HAV was encountered at the age of 1-120 days indicating placental transfer of maternal anti-HAV. In the 1-5 year age group there is a sharp drop of anti-HAV to 40%. The anti-HAV of this age group indicates a response to actual infection with HAV. At 12 years the prevalence of anti-HAV is 85%, approaching that of adults. This survey indicates that Lebanon is an endemic area for HAV infection. The age of onset of this infection may be as early as five months, is commonest in the 1-6 year age group and becomes rare again after the age of 12. Finally, fractionation of immunoglobulins of test sera demonstrated that all subjects had their anti-HAV activity in the IgG class, denoting either maternal transfer or old infection and acquired immunity.

An unusual cause of rhabdomyolysis following surgery in the prone position.

Rhabdomyolysis, as a complication of prone positioning of patients during surgery, is rare. Previous case reports have suggested that the common cause of rhabdomyolysis during the postoperative period is ischemic muscle injury resulting from the use of a tourniquet, occlusion of pelvic blood vessels, or prolonged severe hypotension. We present two cases of this occurrence resulting from compression of the thighs by gel pads of the Jackson frame used to position these patients.

Cerebral oximetry during circulatory arrest for aneurysm surgery.

A patient underwent surgical clipping of a complex giant intracranial carotid aneurysm with the aid of extracorporeal circulation and complete hypothermic circulatory arrest. During the entire procedure, cerebrovascular oxygen saturation (ScO2) was spectroscopically measured. The patient experienced circulatory arrest for 34 min; for 15 of the 34 min ScO2 was < 34% (minimum 32%). The patient tolerated the procedure without new neurological deficit, thus demonstrating that the previously suggested "critical" level of 35% ScO2 is not absolute.

An assessment of contributions made by extracranial tissues during cerebral oximetry.

This study was designed to determine the extent of contribution made by extracranial tissues to estimation of regional cerebrovascular saturation (ScO2) during cerebral oximetry. Thirty four patients undergoing carotid endarterectomy under regional anesthesia were studied. Bilateral ScO2 monitoring with two INVOS 3100 A cerebral oximeters was used. Effect of occlusion of external carotid artery (ECA) for five minutes on ScO2 readings followed by occlusion of internal and common carotid arteries was studied. ScO2 readings at 1 minute intervals were stored on computer disks for off-line analysis. Numerical data were subjected to a two way repeated measures analysis of variance to study the effect of side (ipsilateral or contralateral) and phase (pre clamp, ECA clamp, ICA clamp and post clamp) of operation. A value of p<0.05 was considered significant. There was no significant change in ScO2 on the contralateral side. On the ipsilateral hemisphere ScO2 decreased from 67.4+/-8.5 to 65.6+/-8.3 with ECA occlusion and to 61.4+/-9.6 after ICA occlusion returning to 64.8+/-9.8 after all clamps were released. Decrease after ECA occlusion was not significant (p = 0.12) while that after ICA occlusion was significant when compared to pre clamp value (p<0.001). After release of all clamps ipsilateral ScO2 returned toward baseline but remained significantly lower (p<0.05) than pre clamp values. When readings from two hemispheres were compared, a significant difference (p<0.001) was noted during ICA occlusion only. We conclude that the mathematical algorithm used for calculation of ScO2 by INVOS 3100 A cerebral oximeter measures predominantly the intracranial cerebrovascular saturation.

The effect of hemorrhagic shock on plasma amino acids and tissue energy substrates in the primate.

Levels of plasma amino acids and muscle concentrations of energy substrates and metabolites after shock in the Macaca mulatta Rhesus monkey were investigated. The hemodynamic response to shock is similar to that of previously reported studies of primates in shock. Plasma glucose and ASAT increased significantly, while levels of ALAT and pyruvic acid did not change. Lactic acid was elevated. Muscle glycogen and concentrations of lactic acid were increased, and levels of pyruvic acid, creatine phosphate, and malate fell during shock. Levels of ATP in muscle were unchanged. Nine of the 23 arterial plasma amino acids analyzed decreased significantly. Aspartic acid was increased during shock. The increased levels of tissue carbohydrates and decreased concentrations of plasma amino acids observed in this study differ from results previously reported for other animal shock models. Changes in amino acid levels are similar to the results of some clinical studies.

A study of aspirin induced changes in bleeding time, platelet aggregation, and Sonoclot coagulation analysis in humans.

The purpose of this study was to determine whether or not a newer test of platelet function, Sonoclot coagulation analysis, can identify the patients who develop significant prolongation of bleeding time after aspirin ingestion. Template bleeding time, platelet aggregation in response to arachidonic acid, collagen, epinephrine, adenosine diphosphate, and ristocetin, and Sonoclot coagulation analysis were performed before and after ingestion of aspirin in 22 adult volunteers. Mean bleeding time increased from 5.32 +/- 2.16 min to 7.34 +/- 2.1 min, but remained within normal range (2.5 to 9 min). There was marked intersubject variability in the effect of aspirin on bleeding time, and difference between men and women was not significant. There was significant decrease in platelet aggregation in response to arachidonic acid, collagen and epinephrine. Sonoclot coagulation analysis did not show significant effect of aspirin administration. There was no correlation among changes in bleeding time, platelet aggregation, and Sonoclot coagulation analysis. Five patients with known platelet function disorders and prolonged bleeding times (mean = 18.5 min, range 14 to 22) without any other coagulation abnormalities were also studied. In four of these patients who had normal platelet count, Sonoclot graphs were morphologically similar to those in the volunteers with normal bleeding times, but in one patient with thrombocytopenia, morphology was altered. It is our conclusion that Sonoclot coagulation analysis is unlikely to identify patients with prolonged bleeding time in whom platelet count and other coagulation factors are normal.

Helicobacter pylori in children and adolescents.

There is now considerable evidence that suggests that the H. pylori organism isa human pathogen. The strong association between H. pylori and gastroduodenal disease is well documented. A number of hypotheses have been suggested for the pathogenic mechanisms of H. pylori-induced gastroduodenal disease, including the presence of bacterial virulence factors, the production of inflammatory mediators, disregulation of acid secretion, and the host immune response. At the present time, treatment with a combination of a proton pump inhibitor and antimicrobial agents continues to be recommended for the treatment of H. pylori-associated peptic ulcer disease.

A study of radiologic imaging techniques and airway grading to predict a difficult endotracheal intubation.

STUDY OBJECTIVES: To study whether a detailed radiographic examination of neck and upper airway can help identify normal looking patients in whom endotracheal intubation may be difficult; determine whether such parameters as identified by magnetic resonance imaging (MRI) can also be identified in a soft tissue radiograph; and to study the correlation between oropharyngeal appearance, based on Mallampati's classification, and laryngoscopic findings in a large number of patients requiring endotracheal intubation. DESIGN: Prospective. SETTING: University medical center. PATIENTS: 20 adult patients in whom an unanticipated difficult endotracheal intubation was encountered, and a control group of 20 patients in whom endotracheal intubation was easily accomplished. INTERVENTIONS: Difficult-to-intubate patients were identified according to prospectively established criteria. Control subjects, in whom the trachea was easily intubated, were matched for age, gender, height, weight, and oropharyngeal appearance. MEASUREMENTS AND MAIN RESULTS: In all 40 study patients, a soft tissue radiograph and an MRI scan of the neck were obtained. We measured 21 parameters from both radiographic studies. There were no significant differences between the two groups in 20 of 21 measured parameters on MRI scans and soft tissue radiographs. Only one measurement--the distance between the uppermost visible part of the airway and the posterior pharyngeal wall (measured from MRI scans only)--between the two groups achieved statistical significance. The values recorded from MRI and soft tissue radiographs were not significantly different. Airway grading system first suggested by Mallampati had a fair correlation with laryngoscopy findings associated with a difficult endotracheal intubation. CONCLUSIONS: No significant difference between the two groups could be identified on soft tissue radiography or MRI scans.

Removal of copper(II) from some environmental samples by sorptive-flotation using powdered marble wastes as sorbents and oleic acid as surfactant.

A simple and economic experimental sorptive -flotation procedure is presented for the removal of copper(II) species from aqueous solutions. It is based on using powdered marble wastes (PMW), which are widespread and inexpensive and may represent an environmental problem, as the effective inorganic sorbent and oleic (HOL) as the surfactant. The main parameters (i.e. initial solution pH, sorbent, surfactant and copper concentrations, stirring times, ionic strength, temperature and the presence of foreign ions) influencing the flotation of PMW and /or Cu(II) were examined. Nearly, 100% of PMW and Cu(II) were removed from aqueous solutions at pH7 after stirring for 10 min and at room temperature, (approximately 25 degrees C). The procedure was successfully applied to recover Cu(II) spiked to some natural water samples. A mechanism for sorption and flotation is suggested.