Association of epicardial adipose tissue with early structural and functional cardiac changes in Type 2 diabetes.

BACKGROUND: Dysregulated epicardial adipose tissue (EAT) may contribute to the development of heart failure in Type 2 diabetes (T2D). This study aimed to evaluate the associations between EAT volume and composition with imaging markers of subclinical cardiac dysfunction in people with T2D and no prevalent cardiovascular disease. METHODS: Prospective case-control study enrolling participants with and without T2D and no known cardiovascular disease. Two hundred and fifteen people with T2D (median age 63 years, 60 % male) and thirty-nine non-diabetics (median age 59 years, 62 % male) were included. Using computed tomography (CT), total EAT volume and mean CT attenuation, as well as, low attenuation (Hounsfield unit range -190 to -90) EAT volume were quantified by a deep learning method and volumes indexed to body surface area. Associations with cardiac magnetic resonance-derived left ventricular (LV) volumes and strain indices were assessed using linear regression. RESULTS: T2D participants had higher LV mass/volume ratio (median 0.89 g/mL [0.82-0.99] vs 0.79 g/mL [0.75-0.89]) and lower global longitudinal strain (GLS; 16.1 ± 2.3 % vs 17.2 ± 2.2 %). Total indexed EAT volume correlated inversely with mean CT attenuation. Low attenuation indexed EAT volume was 2-fold higher (18.8 cm3/m2 vs. 9.4 cm3/m2, p < 0.001) in T2D and independently associated with LV mass/volume ratio (ß = 0.002, p = 0.01) and GLS (ß = -0.03, p = 0.03). CONCLUSIONS: Higher EAT volumes seen in T2D are associated with a lower mean CT attenuation. Low attenuation indexed EAT volume is independently, but only weakly, associated with markers of subclinical cardiac dysfunction in T2D.

The Use and Efficacy of FFR-CT: Real-World Multicenter Audit of Clinical Data With Cost Analysis.

BACKGROUND: Fractional flow reserve-computed tomography (FFR-CT) is endorsed by UK and U.S. chest pain guidelines, but its clinical effectiveness and cost benefit in real-world practice are unknown. OBJECTIVES: The purpose of this study was to audit the use of FFR-CT in clinical practice against England's National Institute for Health and Care Excellence guidance and assess its diagnostic accuracy and cost. METHODS: A multicenter audit was undertaken covering the 3 years when FFR-CT was centrally funded in England. For coronary computed tomographic angiograms (CCTAs) submitted for FFR-CT analysis, centers provided data on symptoms, CCTA and FFR-CT findings, and subsequent management. Audit standards included using FFR-CT only in patients with stable chest pain and equivocal stenosis (50%-69%). Diagnostic accuracy was evaluated against invasive FFR, when performed. Follow-up for nonfatal myocardial infarction and all-cause mortality was undertaken. The cost of an FFR-CT strategy was compared to alternative stress imaging pathways using cost analysis modeling. RESULTS: A total of 2,298 CCTAs from 12 centers underwent FFR-CT analysis. Stable chest pain was the main symptom in 77%, and 40% had equivocal stenosis. Positive and negative predictive values of FFR-CT were 49% and 76%, respectively. A total of 46 events (2%) occurred over a mean follow-up period of 17 months; FFR-CT (cutoff: 0.80) was not predictive. The FFR-CT strategy costs £2,102 per patient compared with an average of £1,411 for stress imaging. CONCLUSIONS: In clinical practice, the National Institute for Health and Care Excellence criteria for using FFR-CT were met in three-fourths of patients for symptoms and 40% for stenosis. FFR-CT had a low positive predictive value, making its use potentially more expensive than conventional stress imaging strategies.

Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT.

Objectives: Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood. Methods: UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification. Results: The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations. Conclusion: Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality. Advances in knowledge: On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.

Constructing custom-made radiotranscriptomic signatures of vascular inflammation from routine CT angiograms: a prospective outcomes validation study in COVID-19.

BACKGROUND: Direct evaluation of vascular inflammation in patients with COVID-19 would facilitate more efficient trials of new treatments and identify patients at risk of long-term complications who might respond to treatment. We aimed to develop a novel artificial intelligence (AI)-assisted image analysis platform that quantifies cytokine-driven vascular inflammation from routine CT angiograms, and sought to validate its prognostic value in COVID-19. METHODS: For this prospective outcomes validation study, we developed a radiotranscriptomic platform that uses RNA sequencing data from human internal mammary artery biopsies to develop novel radiomic signatures of vascular inflammation from CT angiography images. We then used this platform to train a radiotranscriptomic signature (C19-RS), derived from the perivascular space around the aorta and the internal mammary artery, to best describe cytokine-driven vascular inflammation. The prognostic value of C19-RS was validated externally in 435 patients (331 from study arm 3 and 104 from study arm 4) admitted to hospital with or without COVID-19, undergoing clinically indicated pulmonary CT angiography, in three UK National Health Service (NHS) trusts (Oxford, Leicester, and Bath). We evaluated the diagnostic and prognostic value of C19-RS for death in hospital due to COVID-19, did sensitivity analyses based on dexamethasone treatment, and investigated the correlation of C19-RS with systemic transcriptomic changes. FINDINGS: Patients with COVID-19 had higher C19-RS than those without (adjusted odds ratio [OR] 2·97 [95% CI 1·43-6·27], p=0·0038), and those infected with the B.1.1.7 (alpha) SARS-CoV-2 variant had higher C19-RS values than those infected with the wild-type SARS-CoV-2 variant (adjusted OR 1·89 [95% CI 1·17-3·20] per SD, p=0·012). C19-RS had prognostic value for in-hospital mortality in COVID-19 in two testing cohorts (high [≥6·99] vs low [<6·99] C19-RS; hazard ratio [HR] 3·31 [95% CI 1·49-7·33], p=0·0033; and 2·58 [1·10-6·05], p=0·028), adjusted for clinical factors, biochemical biomarkers of inflammation and myocardial injury, and technical parameters. The adjusted HR for in-hospital mortality was 8·24 (95% CI 2·16-31·36, p=0·0019) in patients who received no dexamethasone treatment, but 2·27 (0·69-7·55, p=0·18) in those who received dexamethasone after the scan, suggesting that vascular inflammation might have been a therapeutic target of dexamethasone in COVID-19. Finally, C19-RS was strongly associated (r=0·61, p=0·00031) with a whole blood transcriptional module representing dysregulation of coagulation and platelet aggregation pathways. INTERPRETATION: Radiotranscriptomic analysis of CT angiography scans introduces a potentially powerful new platform for the development of non-invasive imaging biomarkers. Application of this platform in routine CT pulmonary angiography scans done in patients with COVID-19 produced the radiotranscriptomic signature C19-RS, a marker of cytokine-driven inflammation driving systemic activation of coagulation and responsible for adverse clinical outcomes, which predicts in-hospital mortality and might allow targeted therapy. FUNDING: Engineering and Physical Sciences Research Council, British Heart Foundation, Oxford BHF Centre of Research Excellence, Innovate UK, NIHR Oxford Biomedical Research Centre, Wellcome Trust, Onassis Foundation.

Successful Management of a Post-Choledochal Cyst Excision Pancreatic Fistula in an Adult Patient: A Case Report and Literature Review on Risk Factors.

Introduction Choledochal cyst is a premalignant condition and surgical excision with biliary enteric anastomosis is the standard of care. Surgical treatment in adults may be difficult due to associated biliary pathology and high incidence of postoperative complications is reported. Postoperative pancreatic fistula (POPF) is a rare early complication following choledochal cyst excision. Material and Methods A 23-year-old male patient was operated for a Todani type IV-A choledochal cyst with anomalous pancreaticobiliary junction. Cyst excision with hepaticojejunostomy was performed. Distal stump closure was technically challenging due to extreme thickening of the cyst wall with neovascularization. On postoperative day 2, patient developed tachycardia and progressive tachypnea with 200 mL of pancreatic fluid in the drain. Endoscopic pancreatic stenting was attempted but was technically not possible. At reexploration, leak from oversewn distal cyst stump was identified and the suture line was reinforced. After the second surgery the patient was hemodynamically stable but continued to have a low output pancreatic fistula for few days which was managed conservatively successfully. We conducted a review of English literature with an aim to identify the risk factors and predictors of pancreatic fistula following cyst excision. An electronic search was performed in Medline and Google Scholar during September 2020 and available literature since January 2000 were reviewed. The keywords used were "pancreatic fistula" and "choledochal cyst." Results Preoperative cholangiography (magnetic resonance cholangiopancreotography/endoscopic retrograde cholangiopancreatography) is essential to know the extent of cyst and delineate biliary pancreatic junction. Literature review including our case revealed that Todani type I-c, type IV, and forme fruste type of choledochal cyst are at high risk of pancreatic injury and POPF. Recurrent cholangitis makes excision technically more challenging and complete removal is not always possible. Conclusion Postoperative pancreatic fistula can be anticipated in select group of patients with high-risk preoperative findings. Chronic inflammation due to recurrent cholangitis promotes scarring and neovascularization which adds to surgical complexity. Operative technique in these high-risk patients needs further refinement.

Single-Stage Off-Pump Hybrid Repair of Kommerell's Diverticulum with Right-Sided Aortic Arch Using a Surgeon-Customized Vascular Prosthesis.

We report the successful single-stage hybrid management of Kommerell's diverticulum associated with a right-sided aortic arch in a 63-year-old woman. She underwent total aortic arch debranching utilizing a surgeon-customized vascular prosthesis, without cardiopulmonary bypass or deep hypothermic circulatory arrest, and concomitant zone-0 endovascular stent-graft deployment.

Assessment, outcomes and implications of multiple anthropometric deficits in children.

BACKGROUND: Malnutrition in children is widely prevalent around the world. It has been observed that malnourished children with multiple anthropometric deficits have higher mortality. However, adequate studies are not available on the outcome and recovery of these children.Nandurbar, a tribal district from Maharashtra, India, shows high prevalence of all three forms of malnutrition, often occurring simultaneously. A project previously undertaken in Nandurbar from July 2014 to June 2016 studied the effect of various therapeutic feeds in treatment of children with uncomplicated severe acute malnutrition (SAM). In this study, we analyse secondary data from it to correlate effects of stunting, wasting and underweight on treatment recovery. METHODS: Analysis was done on 5979 children with SAM using linear and logistic regression on R software for recovery rates and weight gain in children with SAM with single versus multiple anthropometric deficits, their relation to age, sex, and recovery from severe stunting by gain in height. RESULTS: The mean age of children was 35 months and 53.1% of the children were males. 2346 (39.2%) children recovered at the end of the 8-week treatment. 454 (7.6%) had single anthropometric deficit (SAM only), 3164 (52.9%) had two anthropometric deficits (SAM and severe underweight (SUW)) and 2355 (39.4%) children had three anthropometric deficits (SAM, SUW and severe stunting). Out of the 5979 children with SAM, only 52 (0.9%) of children were not underweight (severe or moderate).44.94% of children with SAM who were severely stunted recovered, compared with 35.52% of children who were not (p<0.001). After controlling for confounders, severe stunting was found to increase the odds of recovery by 1.49. Severely stunted children with SAM also showed faster recovery and weight gain by 1.93 days (p<0.012) and 0.29 g/kg/day (p<0.001), respectively. Recovery was higher in females and younger age group. Recovery was also found to depend on the therapeutic feed, with children receiving medical nutrition therapy showing better recovery for severely stunted children. CONCLUSION: Our findings corroborate previous literature that stunting is a way for the body to deal with chronic stress of nutritional deprivation and provides a survival advantage to a child.

Reporting incidental coronary, aortic valve and cardiac calcification on non-gated thoracic computed tomography, a consensus statement from the BSCI/BSCCT and BSTI.

Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.

Outcomes of pain management in chronic pancreatitis: experience from a tertiary care hospital in India.

OBJECTIVES: Chronic pancreatitis (CP) is a progressive inflammatory disorder that leads to irreversible destruction of exocrine and endocrine parenchyma. Little is known about outcomes of CP in the Indian subcontinent. We aim to study the treatment outcomes of CP in terms of pain severity in a tertiary hospital in India. MATERIAL AND METHODS: This is a prospective cohort study of 75 patients diagnosed with CP. Data regarding patient demographics, symptoms, and imaging findings were recorded. Pain severity was recorded objectively by the visual analogue scale (VAS). Cambridge score was calculated, and patients were classified into mild, moderate and severe categories. Patients were treated appropriately, and pain scores were monitored at 3 months and 6 months after initial visit. RESULTS: Alcohol was the most common etiology (54%) followed by idiopathic/unknown causes (34%). Cambridge score or morphology on imaging did not affect pain severity (p>0.05). History of smoking and larger duct diameter decreased the effectiveness of treatment in reducing pain while higher post prandial sugar levels increased effectiveness (p<0.05). Pain relief did not differ between the treatment groups including analgesics, endoscopic or surgery (p>0.05). CONCLUSION: CP presents earlier in the Indian population and represents a unique population with a greater proportion of idiopathic cases than western countries. Rather than pancreatic morphology or Cambridge score alone, a combination of morphology, pain severity and functional status can be utilized for formulating an individualized treatment plan. Present treatment strategies prove effective in treatment of CP.

Structure-Activity Relationship of Polyester-Based Cationic Polyrotaxane Vector-Mediated In Vitro siRNA Delivery: Effect on Gene Silencing Efficiency.

A series of linear polyester-based, α-cyclodextrin (CD)-threaded polyrotaxanes (PRTx) were synthesized for siRNA delivery. The investigation into the effect of the presence of polyester linkages in polyrotaxane established the structural-activity relationship between polyrotaxane and siRNA transfection efficiency. The ester-based polyrotaxane exhibited higher threading efficiency than poly(ethylene glycol)-based polyrotaxane. The threading efficiency is the driving force for transfection, as it regulates the positive charge density on polyrotaxane. Polyester-based polyrotaxane formed stable and effective transfection nanoplexes with siRNA at lower N/P ratios, signifying the high gene loading capacity of the developed supramolecular vectors. Our findings suggest that biochemical properties of the transfection complexes depend on the structure of the axis and threading efficiency of polyrotaxane, which further influences the transfection efficiency. The enhanced gene silencing efficiency and safety are compared with those of extensively explored poly(ethylene glycol)-based polyrotaxane, polyethyleneimine (a gold standard), and lipofectamine (a commercial standard), which are used as siRNA delivery vectors.

In Vivo Studies of 3D Starch-Gelatin Scaffolds for Full-Thickness Wound Healing.

In this study, we have combined the wound-healing properties of two biodegradable polymers, viz., starch and gelatin, and have reinforced their mechanical strength through cross-linking. Further, scaffolds of this polymer combination were used to support an organotypic culture of human skin for wound healing. Human dermal fibroblasts (HDFs) and human epidermal keratinocytes (HEKs) were isolated and were seeded on the scaffolds on days 1 and 7, respectively. The scaffold was then air-lifted to develop a stratified epidermal layer. Hematoxylin and eosin (H&E) staining and immunohistochemical analysis ascertained that the histology of the skin organotypic culture was similar to that of the human skin. For in vivo animal investigations, the scaffolds were transplanted in a full-thickness wound mouse model, as a one-step procedure, wherein the artificial skin substitute showed the presence of well-defined epidermis and formation of stratum basale by day 14. By combining the inherent properties of both the materials, we have synthesized a cost-effective porous scaffold with good mechanical strength and excellent biocompatibility that can be easily adapted for commercial use. The aforementioned scaffold may integrate with the surrounding tissue, accelerate wound closure, and promote tissue reorganization and remodeling.

Anti-inflammatory Effects of Northern Highbush Blueberry Extract on an In Vitro Inflammatory Bowel Disease Model.

Blueberry anthocyanins have the ability to efficiently reach the GI tract and exhibit a broad range of biochemical effects. In the context of inflammatory bowel disease (IBD), they remain a promising complement to current IBD treatments. Here, we investigated the anti-inflammatory and antioxidant capabilities of Highbush blueberries in-vitro on two normal colon epithelial cell lines, NCM 356 and CCD 841 CoN using fluorescent microscopy and flow cytometry following stimulation with a pro-inflammatory cytokine cocktail. Treatment with blueberry extract revealed a significant decrease in nuclear and cytoplasmic generated reactive oxygen species (ROS) compared to controls. Additionally, the blueberry extract increased cell viability following treatment with the pro-inflammatory cytokine cocktail. A comparison with previous report on rice callus suspension culture (RCSC) revealed opposing trend with reference to the levels of nuclear and cytoplasmic ROS. It is likely that blueberry extract and RCSC employ different players and pathways to mitigate inflammation.

Anti-inflammatory and immune-modulating effects of rice callus suspension culture (RCSC) and bioactive fractions in an in vitro inflammatory bowel disease model.

BACKGROUND: Rice callus suspension culture (RCSC) has been shown to exhibit potent antiproliferative activity in multiple cancer cell lines. RCSC and its bioactive compounds can fill the need for drugs with no side effects. HYPOTHESIS/PURPOSE: The anti-inflammatory potential of RCSC and its bioactive fractions on normal colon epithelial cell lines, was investigated. STUDY DESIGN: Three cell lines, InEpC, NCM356 and CCD841-CoN were treated with proinflammatory cytokines followed by RCSC. Cytoplasmic and nuclear ROS were assayed with fluorescent microscopy and flow cytometer. Expression analysis of immune-related genes was performed in RCSC-treated cell lines. RCSC was fractionated using column chromatography and HPLC. Pooled fractions 10-18 was used to test for antiproliferative activity using colon adenocarcinoma cell line, SW620 and anti-inflammatory activity using CCD841-CoN. Mass spectrometric analysis was performed to identify candidate compounds in four fractions. RESULTS: RCSC treatment showed differential effects with higher cytoplasmic ROS levels in NCM356 and CCD841-CoN and lower ROS levels in InEpC. Nuclear generated ROS levels increased in all three treated cell lines. Flow cytometry analysis of propidium iodide stained cells indicated mitigation of cell death caused by inflammation in RCSC treated groups in both NCM356 and CCD841-CoN. Genes encoding transcription factors and cytokines were differentially regulated in NCM356 and CCD841-CoN cell lines treated with RCSC which provided insights into possible pathways. Analysis of pooled fractions 10-18 by HPLC identified 8 peaks. Cell viability assay with fractions 10-18 using SW620 showed that the number of viable cells were greatly reduced which was similar to 6X and 33X RCSC with very little effect on normal cells which similar to 1X RCSC. RCSC fractions increased nuclear and cytoplasmic ROS vs. both untreated and inflammatory control. Analysis of four fractions by mass spectrometry identified 4-deoxyphloridzin, 5'-methoxycurcumin, piceid and lupeol as candidate compounds which are likely to be responsible for the antiproliferative, anti-inflammatory and immune-regulating properties of RCSC. CONCLUSION: RCSC and its fractions showed anti-inflammatory activity on inflamed colon epithelial cells. Downstream target candidate genes which are likely to mediate RCSC effects were identified. Candidate compounds responsible for the antiproliferative and anti-inflammatory activity of RCSC and its fractions provide possible drug targets.

Haemodynamic effects of pharmacologic stress with adenosine in patients with left ventricular systolic dysfunction.

BACKGROUND: In patients with heart failure, downregulation of adenosine receptor gene expression and impaired adenosine-related signal transduction may result in a diminished response to adenosine. This may have implications for cardiac stress testing. We evaluated the haemodynamic response to intravenous adenosine in patients with left ventricular systolic dysfunction (LVSD) undergoing stress cardiovascular magnetic resonance imaging (CMR). METHODS AND RESULTS: We retrospectively examined 497 consecutive patients referred for clinical stress CMR. Blood pressure and heart rate responses with intravenous adenosine were compared in patients with normal, mild-moderately impaired and severely impaired LV systolic function (ejection fraction [EF] > 55%, 36-55% and < 35%, respectively). Following 2 min of adenosine infusion, there was a significant difference between the groups in the heart rate change from baseline, with a diminished heart rate response in patients with LVSD (p < 0.001). An increase in the dose of adenosine (up to 210 µg/kg/min) was required to achieve a sufficient haemodynamic response in more patients with severe LVSD (41%) than those with mild-moderately impaired and normal LV systolic function (24% and 19%, respectively, p < 0.001). Even with increased doses of adenosine in subjects with severe LVSD, peak haemodynamic response remained blunted. With multivariate analysis age (p < 0.001) and LVEF (p = 0.031) were independent predictors of heart rate response to adenosine. CONCLUSION: Patients with reduced LVEF referred for stress CMR may have a blunted heart rate response to adenosine. Further study is warranted to determine whether this may be associated with reduced diagnostic accuracy and also the potential utility of further dose increases or alternative stressors.

Post-mortem computed tomography in adult non-suspicious death investigation-evaluation of an NHS based service.

OBJECTIVE: Post-mortem CT (PMCT) can replace autopsy in many cases of non-suspicious death. A purely NHS-based service to replace autopsy with PMCT was launched, with the cost met by the family from 2015 to 2017, and subsequently "free at the point of delivery" after local authority funding was secured. The aim of the service was to improve the experience for the families. This report describes and evaluates the service against local standards of (1) less than four day turn around, (2) cause of death given in >90% and (3) less than 10% require autopsy. METHODS: A retrospective review of reports, records and emails was undertaken to collate demographics, times of different stages of the process, the outcome and comments from service users. RESULTS: Between July 2015 and July 2018, 279 patients had PMCT scans, 67 (24.0%) in the family-funded service and 212 (76%) in the current service. 97.1% (n = 271/279) of cases had the radiology report issued by day 3 (96.8% vs 98.6% for the family funded and local authority-funded services respectively). A cause of death was given in 97.2% of scans. 2.8% of patients required autopsy. Feedback from families, coroner's officers and undertakers has been overwhelmingly positive. CONCLUSION: The services exceeded local standards and met the needs of the Coroner and the families based on the feedback received. This model could be employed for similar services, but the change to the logistics and financial structures required to initiate such services remains a significant hurdle. ADVANCES IN KNOWLEDGE: This is the first report of a fully NHS-based PMCT service.

A prospective study of efficacy and safety of rubber band ligation in the treatment of Grade II and III hemorrhoids - a western Indian experience / Estudo prospectivo da eficácia e segurança da ligadura elástica no tratamento de hemorroidas de Grau II e III - uma experiência na Índia ocidental

ABSTRACT Background: Hemorrhoids are one of the most frequent diseases of the anal region with high prevalence involving all age groups. Multiple treatment options exist with none being perfect. Rubber band ligation of hemorrhoids is a non-operative treatment which can be performed on outpatient basis. Objective: The study was undertaken to determine efficacy of banding in treatment of Grade II and III hemorrhoids and to follow-up patients treated by banding to evaluate for symptomatic relief, recurrence and complications. Study design: A prospective, interventional study with clearance from the institutional ethics committee was undertaken over the period of 2 years in a tertiary referral center with a sample size of 60. Result: Out of 60 patients, 41 patients (68.30%) had Grade II and 19 patients (31.7%) had Grade III hemorrhoids. At first follow up, success rate for Grade II hemorrhoids was 85% (35/41) as compared to 21% (4/19) in Grade III. The unsuccessful 20 patients were re-banded, however only 2 of them responded to procedure. At the end of 6 weeks, 36 patients with Grade II hemorrhoids (88%) were cured. Failure rate was higher for Grade III hemorrhoids (68.42%, n = 13). Success rate was 86.6% for single hemorrhoid. There were no major complications. Anemia reverted significantly with successful band ligation. Conclusion: Rubber band ligation is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an outpatient procedure. It gives better results for Grade II and single hemorrhoids. Recurrence rate after successful band ligation is low.

RESUMO Background: As hemorroidas são uma das doenças mais frequentes da região anal, com alta prevalência envolvendo todas as faixas etárias. Existem várias opções de tratamento, sendo que nenhuma é perfeita. A ligadura elástica de hemorroidas é um tratamento conservador que pode ser realizado em ambulatório. Objetivo: O estudo foi realizado para determinar a eficácia da ligadura no tratamento de hemorroidas de Grau II e III e para acompanhamento dos pacientes tratados por ligaduras para avaliar o alívio sintomático, a recorrência e as complicações. Design do estudo: Estudo prospectivo e intervencionista com liberação do comitê de ética institucional foi realizado durante o período de 2 anos em um centro de referência terciário com um tamanho de amostra de 60. Resultado: Dos 60 pacientes, 41 (68,30%) apresentaram hemorroidas de Grau II e 19 (31,7%) de Grau III. No primeiro seguimento, a taxa de sucesso para hemorroidas de grau II foi de 85% (35/41), em comparação com 21% (4/19) no Grau III. Os 20 pacientes sem sucesso foram novamente submetidos a ligadura, mas apenas 2 deles responderam ao procedimento. Ao final de 6 semanas, 36 pacientes com hemorroidas de Grau II (88%) foram curados. A taxa de falha foi maior para as hemorroidas de grau III (68,42%, n = 13). A taxa de sucesso foi de 86,6% para hemorroida única. Não houve grandes complicações. A anemia reverteu significativamente com ligadura elástica bem-sucedida. Conclusão: A ligadura elástica é um método simples, seguro e eficaz para o tratamento de hemorroidas sintomáticas de segundo e terceiro graus, como procedimento ambulatorial. Ela promove melhores resultados para hemorroidas de Grau II e únicas. A taxa de recorrência após ligadura elástica bem-sucedida é baixa.

Starch based nanofibrous scaffolds for wound healing applications.

Starch is an attractive polymer for wound healing applications because of its wide availability, low cost, biocompatibility, biodegradability and wound-healing property. Here, we have fabricated starch-based nanofibrous scaffolds by electrospinning for wound healing applications. The diameter of the optimized nanofibers was determined by field emission scanning electron microscopy (FE-SEM) and was found to be in the range of 110-300 nm. The mechanical strength (0.5-0.8 MPa) of the nanofibrous scaffolds was attuned using polyvinyl alcohol (plasticizer) and glutaraldehyde (crosslinking agent), to impart them with sufficient durability for skin tissue engineering. Absence of negative interactions between the polymers was confirmed by Attenuated Total Reflectance-Fourier Transform Infrared Spectroscopy (ATR-FTIR), differential scanning microscopy (DSC) and thermal gravimetric analysis (TGA). Cellular assays with L929 mouse fibroblast cells indicated the ability of the scaffolds to promote cellular proliferation, without exhibiting any toxic effect to the cells. Thus, the nanofibrous scaffolds demonstrated potential for wound healing applications.

Dermatologist and Patient Preferences in Choosing Treatments for Moderate to Severe Psoriasis.

INTRODUCTION: The objective of the study was to determine the relative importance (RI) of treatment attributes psoriasis patients and physicians consider when choosing between biologic therapies based on psoriasis severity. METHODS: A discrete choice experiment (DCE) weighting preference for eight sets of hypothetical treatments for moderate or severe psoriasis was conducted. DCE hypothetical treatments were defined and varied on combinations of efficacy, safety, and dosing attributes [frequency/setting/route of administration (ROA)]. RESULTS: When assuming moderate psoriasis in the patient DCE, ROA (RI 29%) and efficacy (RI 27%) drive treatment choices. When assuming severe disease in the DCE, patients preferred treatments with higher efficacy (RI 36%); ROA was relatively less important (RI 15%). From the physician perspective, ROA (RI 32%) and efficacy (RI 26%) were most important for moderate psoriasis patients. In the physician model for severe psoriasis, efficacy (RI 42%) was the predominant driver followed by ROA (RI 22%). Regardless of severity, probability of loss of response within 1 year was the least important factor. CONCLUSIONS: The severity of disease is a critical element in psoriasis treatment selection. There are high levels of alignment between physician- and patient-derived preferences in biologic treatment choice selection for psoriasis. FUNDING: Janssen Pharmaceuticals.