Does Laparoscopic Omentectomy Reduce CAPD Catheter Malfunction: A Three-arm Pilot Randomized Trial.

Introduction: Catheter malfunction secondary to omental wrapping is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Of the various methods of peritoneal dialysis catheter insertion (PDCI), open surgical insertion under local anesthesia is most widely practiced. Laparoscopic omentectomy is often undertaken as a salvage procedure in case of malfunctioning catheters. However, there is no randomized controlled trial (RCT) to evaluate the role of prophylactic laparoscopic omentectomy on catheter function. This pilot RCT was undertaken to evaluate the impact of laparoscopic omentectomy on the incidence of catheter malfunction. Materials and Methods: Consecutive patients were randomized into three groups: laparoscopic PDCI with omentectomy (Group A), laparoscopic PDCI without omentectomy (Group B) and open surgical PDCI (Group C). The primary outcome was the incidence of catheter malfunction at 6 weeks and 3 months. Results: Forty-one patients completed follow-up, with 16, 11, and 14 patients in Groups A, B, and C, respectively. Incidence of catheter malfunction was 6.2%, 27.3%, and 14.3% in Groups A, B, and C, respectively, at 6 weeks and 6.2%, 36.4%, and 21.4% at 3 months, respectively. In patients with previously failed catheter insertion (n = 23), malfunction at 3 months was 8.3% (1/12) in patients who had omentectomy, compared with 45.5% (5/11) in those who did not (P = 0.069). Operating time was significantly higher (P < 0.001) in Group A. Conclusions: Laparoscopic omentectomy may be associated with a lower incidence of catheter malfunction, especially in patients with previously failed peritoneal dialysis catheter. Data from this pilot RCT can be used to design a large trial with an adequate number of patients.

Effect of short-term meditation training in central serous chorioretinopathy.

PURPOSE: Stress and Type A personality are established risk factors for the development of central serous chorioretinopathy (CSC). Meditation is known to have a positive effect on reducing stress levels. This study aimed to assess the effect of short-term meditation training in patients of CSC. METHODS: A pilot study was conducted where 40 patients diagnosed with acute and non-resolving CSC were randomly assigned to either of two groups - meditation training and routine care (without meditation). The primary outcome measure was time to resolution of CSC based on optical coherence tomography and fluorescein angiography. Secondary outcome measures were changes in anxiety score (State-Trait Anxiety Inventory [STAI] scores) and blood pressure. The patients were followed up for a minimum period of 4 months. RESULTS: Twenty cases were included in each group. The demographic pattern, baseline swept-source optical coherence tomography parameters, and STAI scores were similar in both groups. The time to disease resolution was 9.4 ± 4.22 weeks in the meditation group and 19.5 ± 2.79 weeks in the nonmeditation group (P < 0.001). At 4 months, CSC had failed to resolve in 60% of patients with routine care compared with 8% in cases following short-term meditation training. STAI scores showed a reduction in stress levels in the meditation group. Furthermore, statistically significant improvement in systolic and diastolic blood pressures was also observed following meditation training. CONCLUSION: Short-term meditation training may be a useful approach in the management of patients with CSC as it tends to reduce stress and prehypertension, and promotes earlier resolution of the condition. However, patient's motivation to complete and pursue the meditation training is a significant barrier.

To Study the Impact of Donor Nephrectomy on Blood Pressure as Measured by Ambulatory Blood Pressure Monitoring and Renal Function.

Prospective living kidney donors need meticulous evaluation prior to kidney donation. Ambulatory blood pressure monitoring (ABPM) is considered the reference standard for diagnosing hypertension. With no prior study available in India in this context, we undertook this study to evaluate the utility of ABPM in kidney donors and effect of donor nephrectomy on renal function. This was a prospective observational study involving healthy prospective kidney donors between 18 and 70 years with normal office blood pressure measurements (OBPM). Detailed clinical and biochemical parameters were recorded. OBPM and 24-hour ABPM was done preoperatively and 3 months following donor nephrectomy. There were 51 donors with a mean age of 46.1 ± 11.3 years, of which 40 (78.4%) were females. Preoperatively, three (5.8%) donors were hypertensive on ABPM but normal on OBPM (P = 0.08). Three months post nephrectomy, hypertension was present in seven (13.7%) donors by ABPM, while only two (3.9%) donors were diagnosed as hypertensive by OBPM (P = 0.02). Median pre-nephrectomy proteinuria was 70 mg (10 mg-180 mg) with a mean estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) formula of 86.86 ± 19.1 ml/min. Six donors developed >300 mg/day proteinuria, and 17 (33.3%) had a 24-hour urinary protein excretion greater than 150 mg/day. Mean serum creatinine (0.79 ± 0.11 vs 1.03 ± 0.16 mg/dl) significantly increased post donation, more so in donors >55 years of age (1.14 ± 0.25 mg/dl). Our study shows that in transplant donors, ABPM is better for diagnosing hypertension, which otherwise remains masked in 10% of the donors on routine OBPM. Significance of post-nephrectomy hypertension and increasing proteinuria needs further evaluation.

Novel Heterozygous Mutations of Congenital Thrombotic Thrombocytopenic Purpura: A Rare Case Report.

Hereditary thrombotic thrombocytopenic purpura (TTP) is a genetic condition caused by mutations in ADAMTS13 gene, leading to very low levels of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type I domain 13) activity. It is a rare condition associated with multiple reported mutations. Here, we describe a case of hereditary TTP with a compound novel heterozygous mutation along with secondary focal segmental glomerulosclerosis. The patient responded clinically to plasma infusions with resolution of thrombocytopenia, stabilization of renal function, and control of blood pressures. Genetic analysis of the entire family helped in the characterization of the inheritance of this mutation. Our case illustrates the need for focused genetic analysis in a subset of patients presenting with features of TTP to decide the therapeutic plan and manage accordingly.

Meditation enhances brain oxygenation, upregulates BDNF and improves quality of life in patients with primary open angle glaucoma: A randomized controlled trial.

BACKGROUND: Glaucoma (POAG) is a kind of neurodegenerative disease known to be closely associated with stress and adverse quality of life (QOL). Stress has also been shown to be involved in etiopathogenesis of primary open angle glaucoma (POAG). Complementary treatment in form of Meditation has been reported to improve QOL, brain oxygenation and decrease markers of stress. With this premise, a randomized controlled trial was carried out to assess the effect of Meditation on intraocular pressure, subjective QOL and objective markers of stress and brain oxygenation in patients with POAG. METHODS: Sixty patients were randomized into intervention and control groups. Intervention group underwent 45 minutes of Meditation daily for 6 weeks in addition to standard medical treatment while controls received only standard medical treatment. Inclusion criteria were patients with POAG, age >45 years, best corrected visual acuity >6/60. Patients with other ocular co-morbid conditions contributing to vision loss, systemic diseases, patients already practicing meditation in any form were excluded. An assessment of IOP, brain oxygenation using functional near infrared spectroscopy (fNIRS), QOL (WHO-BREF QOL) and stress markers in serum (cortisol, ß-endorphins, interleukin-6, brain derived neurotrophic factor (BDNF), reactive oxygen species) was made at baseline and at 6 weeks. RESULTS: 21 female and 39 male patients were enrolled with a mean age of 57.28±9.37 years. All parameters were comparable between two groups at baseline. At 6 weeks mean level of IOP decreased significantly in intervention group (15.9±1.8 mmHg to 14.4±1.21 mm Hg, p-value 0.0001) as compared to control group (15.7±1.4 mmHg to 15.65±1.41, p-value 0.41). fNIRS showed significant improvement in oxygenated hemoglobin change (ΔHbO) in intervention group in the prefrontal cortex (p-value <  0.0001) as compared to control group (p-value 0.52). WHO-BREF QOL score increased significantly in intervention group (86.6±6.16 to 93.3±5.66, p-value 0.0001) as compared to control (89±7.25 to 89.07±3.24, p-value 0.74).Mean serum cortisol decreased significantly in intervention group (497±46.37 ng/ml to 447±53.78 ng/ml, p-value 0.01) as compared to control group (519.75±24.5 to 522.58±26.63 ng/ml, p-value 0.64). Mean ß-endorphin levels increased significantly (33±5.52pg/ml to 43.27pg/ml, p-value <  0.0001) as compared to control group (34.78±4.1pg/ml to 36.33pg±4.07pg/ml p-value 0.27). Interleukin-6 decreased significantly in intervention group (2.2±0.5 ng/ml to 1.35±0.32 ng/ml, p-value <  0.0001) as compared to control group (2.03±0.37 to 2.17±0.34 ng/ml p-value 0.25). BDNF increased significantly in intervention group (52.24±6.71 to 63.25±13.48 ng/ml p-value 0.004) as compared to control group (53.23±5.82 to 54.42±5.66 ng/ml p-value 0.54). ROS decreased significantly in intervention group (1596.19±179.14 to 1261±244.31 RLU/min/104 neutrophils p-value 0.0001) as compared to control group (1577.5±172.02 to 1662.5±84.75 RLU/min/104 neutrophils p-value 0.16). CONCLUSIONS: A short term course of Meditation was associated with significant improvement in brain oxygenation and QOL along with a reduction in IOP and stress markers. Meditation may be a useful as an adjunct to standard treatment in patients with POAG and potentially decrease the risk of glaucoma progression.

Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial.

BACKGROUND: Reducing intraocular pressure (IOP) in primary open-angle glaucoma (POAG) is currently the only approach to prevent further optic nerve head damage. However, other mechanisms such as ischemia, oxidative stress, glutamate excitotoxicity, neurotrophin loss, inflammation/glial activation, and vascular dysregulation are not addressed. Because stress is a key risk factor affecting these mechanisms, we evaluated whether mindfulness-based stress reduction can lower IOP and normalize typical stress biomarkers. MATERIALS AND METHODS: In a prospective, randomized trial 90 POAG patients (180 eyes; age above 45 y) were assigned to a waitlist control or mindfulness meditation group which practiced daily for 21 days. We measured IOP (primary endpoint), quality of life (QOL), stress-related serum biomarkers [cortisol, ß-endorphins, IL6, TNF-α, brain-derived neurotrophic factor (BDNF), reactive oxygen species (ROS), total antioxidant capacity (TAC)], and whole genome expression. RESULTS: Between-group comparisons revealed significantly lowered IOP in meditators (OD: 18.8 to 12.7, OS 19.0 to 13.1 mm Hg) which correlated with significantly lowered stress-biomarker levels including cortisol (497.3 to 392.3 ng/mL), IL6 (2.8 to 1.5 ng/mL), TNF-α (57.1 to 45.4 pg/mL), ROS (1625 to 987 RLU/min/104 neutrophils), and elevated ß-endorphins (38.4 to 52.7 pg/mL), BDNF (56.1 to 83.9 ng/mL), and TAC (5.9 to 9.3) (all P<0.001). These changes correlated well with gene expression profiling. Meditators improved in QOL (P<0.05). CONCLUSIONS: A short course of mindfulness-based stress reduction by meditation in POAG, reduces IOP, improves QOL, normalizes stress biomarkers, and positively modifies gene expression. Mindfulness meditation can be recommended as adjunctive therapy for POAG.

Dengue fever in renal allograft recipients: Clinical course and outcome.

BACKGROUND: There are annual outbreaks of dengue infection in tropical and subtropical countries. This retrospective study aimed to assess the clinical manifestation of dengue and outcome in renal transplant recipients. METHODS: Renal transplant recipients diagnosed with dengue in the nephrology department during the outbreak from August 2015 to December 2015 were included in the study. RESULTS: Twenty patients developed dengue presenting during the outbreak. Mean age was 31.9 ± 8.8 years and all were males. Two patients had severe dengue (dengue hemorrhagic fever, dengue shock syndrome). Clinical presentation included febrile illness (95%), myalgia (65%), headache (30%), retro-orbital pain (10%), and mucocutaneous bleeding manifestations (10%). Three (15%) had third space fluid accumulation and 2 (10%) had hypotension. Ninety percent patients had thrombocytopenia, with 4 requiring platelet transfusion. Leucopenia (WBC < 4000/mm3 ) developed in 50% patients. About 60% had transient transaminitis. One patient with severed dengue expired and 1 recovered with IV immunoglobulin therapy. About 40% patients had rise in serum creatinine, with complete recovery in all patients. CONCLUSION: Clinical manifestations of dengue infection in renal transplant recipients were similar to that in general population. However, leucopenia necessitating temporary withdrawal of immunosuppression was common. Renal dysfunction was frequent but completely reversible.

Acute aortoiliac thrombotic occlusion in an infant with protein C deficiency and small atrial sepal defect--a rare case.

Aortoiliac thrombosis is rare in infants and neonates. Protein C deficiency is frequently observed with venous thromboembolism, but off-late report of arterial thrombosis is increasingly common. We report a case of large infrarenal aortoiliac saddle and right popliteal artery thrombosis in a 7-month-old infant, with 3-mm atrial septal defect without clinical and Doppler evidence of deep vein thrombosis, presented with acute bilateral lower limb ischemic attack. Diagnosis was made by computed tomographic (C T) angiography of aorta and bilateral lower limbs. Patient operated on in emergency by transperitoneal route. Aortoiliac and right popliteal artery thromboembolectomy with closure of aortotomy with polytetraflouroethylene patch was performed.

Association between thyroid hormones, insulin resistance, and metabolic syndrome.

OBJECTIVE: To determine the association between thyroid hormones, insulin resistance, and metabolic syndrome in euthyroid women. METHODS: Forty-five women with no past medical history were studied in this cross-sectional study at the Department of Endocrinology, Medwin Hospitals, Hyderabad, India, from August 2008 to September 2008. The body fat was estimated using bio-impedance method, and fasting blood sample was analyzed for total triiodothyronine (T3), total thyroxine (T4), thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), lipid profile, insulin, and glucose. RESULTS: The mean age of the participants was 32.6 +/= 9.6 years with a body mass index (BMI) of 29.9 +/= 3.8 kg/m2. Evidence of homeostasis model assessment index for insulin resistance (HOMA-IR) more than 3 was seen in 34 (75%) and metabolic syndrome in 29 (64%) participants. Total T3 showed a positive correlation with triglycerides, low density lipoprotein- cholesterol (LDL-C), total cholesterol, insulin, HOMA-IR and negatively with body fat. Thyroid-stimulating hormone correlated positively with BMI, insulin, HOMA-IR, LDL-C and negatively with HDL-cholesterol (p<0.05). Free triiodothyronine correlated positively with waist circumference and T4 did not correlate with metabolic syndrome parameters. CONCLUSION: Our preliminary data show an association between thyroid hormones and some components specific of the metabolic syndrome in euthyroid women. Total triiodothyronine and TSH correlated more with variables of metabolic syndrome than FT3 and T4.

A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus.

OBJECTIVES: The objective of the study was to study the short-term impact of a brief lifestyle intervention based on yoga on some of the biochemical indicators of risk for cardiovascular disease and diabetes mellitus. DESIGN: The variables of interest were measured at the beginning (day 1) and end (day 10) of the intervention using a pre-post design. SETTING: The study is the result of operational research carried out in our Integral Health Clinic (IHC). The IHC is an outpatient facility which conducts 8-day lifestyle modification programs based on yoga for prevention and management of chronic disease. A new course begins every alternate week of the year. SUBJECTS: The study is based on data collected on 98 subjects (67 male, 31 female), ages 20-74 years, who attended one of our programs. The subjects were a heterogeneous group of patients with hypertension, coronary artery disease, diabetes mellitus, and a variety of other illnesses. INTERVENTION: The intervention consisted of asanas (postures), pranayama (breathing exercises), relaxation techniques, group support, individualized advice, lectures and films on the philosophy of yoga and the place of yoga in daily life, meditation, stress management, nutrition, and knowledge about the illness. OUTCOME MEASURES: The outcome measures were fasting plasma glucose and serum lipoprotein profile. These variables were determined in fasting blood samples, taken on the first and last day of the course. RESULTS: Fasting plasma glucose, serum total cholesterol, low-density lipoprotein (LDL) cholesterol, very- LDL cholesterol, the ratio of total cholesterol to high density lipoprotein (HDL) cholesterol, and total triglycerides were significantly lower, and HDL cholesterol significantly higher, on the last day of the course compared to the first day of the course. The changes were more marked in subjects with hyperglycemia or hypercholesterolemia. CONCLUSIONS: The observations suggest that a short lifestyle modification and stress management education program leads to favorable metabolic effects within a period of 9 days.